24 2 RPD

Scientific Journal Published by the
College of Dentistry – University of Baghdad
Vol. 24 No. 2 2012

ISSN
ISSN
1680-0087
A quarterly peer reviewed published scientific journal of the College of Dentistry,
University of Baghdad.
Editor in chief: Prof. Dr. Nabil Abdulfatah Hatoor, M.Sc
Vice editor in chief: Prof. Dr. Hussain Faisal Al-Huwaizi M.Sc., PhD
National Members International Members

Prof. Dr. Adel Farhan MSc Prof. J. L. Gutmann D.D.S., Ph.D.(USA)
Prof. Dr. Zainab Al-Dahan MSc Prof. Dr. M. Goldberg PhD (France)
Prof. Dr. Abbas Sabri M.Sc., PhD
Prof. Dr.Wasan Hamdi M.Sc, PhD
Assist. Prof. Dr. Leka’a Mahmood M.Sc
Assist. Prof. Dr. Sabah Nema M.Sc., PhD
Prof. Dr. Nidhal Hussain MSc
Assist. Prof. Dr. Sahar Shaker MSc
Assist. Prof. Dr. Ghassan Abdulhameed
MSc
Board of editorial consultants:

1- Prof. Dr. Majida Al-Hashimi MSc 5- Prof. Dr. Shatha Saleem MSc
2. Prof. Dr. Akram Al-Huwaizi MSc, PhD 6- Assist. Prof. Dr. Maha Shukri MSc
3- Prof. Dr. Mohammad Al-Qaisi MSc 7- Assist. Prof. Dr. Abbas Fadhil PhD
4- Prof. Dr. Raja Hadi MSc, PhD 8- Lecturer Dr. Jamal Abid MSc
Secretarial committee:
1- Lecturer Dr. Mohammad Nahidh
2- Lecturer Yassir AbdulKadum
3- Assist. Lecturer Ahmed Fadhil
4- Assist. Lecturer Ayad M. Al-Obaidi
For consultation, please contact:
Website: www.codental.uobaghdad.edu.iq
E-mail: baghdad_dentistry@yahoo.com
Telephone: (+9641)4169375 Fax: (+9641)4140738
i
Contents
i Editor and Editorial Board
ii Contents
v Instructions for the Authors
Restorative Dentistry
Effect of different metal surface treatments and thermocycling on shear bond strength of heat cure and
1 light cure at Co/Cr and Ni/Cr interface. Ali M. Khursheed, Salah A. Mohammed.
Comparison of certain mechanical properties including deflection fatigue resistance of Cobalt Chromium
6 alloy & Nylon tooth colored clasping materials. Azhar Imran Majeed Al-Awady, Widad Abdul-Hadi Al-
Nakkash
A comparison of the retention of complete denture bases having different types of posterior palatal seal
11 with different palatal forms. Mayada Qasim Abdul Khafoor
An evaluation of the use different techniques of the thermoplasticized obturators on the coronal seal
18 Mervat M. Al-Bakri, Hussain F. Al-Huwaizi
An evaluation of apical microleakage in roots filled with thermoplastic synthetic polymer based root
21 canal filling material (RealSeal 1 bonded obturation). Nadine J. Adbul-rada, Adel F. Ibraheem
The effect of two types of disinfectant on shear bond strength, hardness, roughness of two types of soft
27 liners. Rola W. Abdul-Razaq
Oral Diagnosis
Immunohistochemical detection to evaluate the biological role of Ti implants coated by a combination of
32 fibronectin protein and hydroxyapitate (EPD) (in vivo study). Athraa Y.Al-Hijazi, Thair L-Al-Zubaydi,
Eman Issa Mahdi
Evaluation of 900 mhz mobile phone effects on palate and tooth germ development in mouse embryo
39 (histological & immunohistochemical study). Faten H. Berto, Athraa Y. Al-Hijazi
Chronological ِage estimation in adolescent and young adult subjects in relation to mandibular third
47 molar development using digital panoramic image. Jaafar J. Attar, Jamal Ali AL-Taei
Diagnosis of the angular hyperkeratotic lesions and the incidence of the etiologic factors. Jamal N.
51 Ahmed
ii
Pre-implant computed tomography and insertion torque measurement in qualitative determination of
56 trabecular bone density. Mahmood J. Hamzah, Jamal A. Al-Taei
Evaluation of oral health status in a sample of autistic male children. Mayyadah H. Rashid, Raja H. Al-
62 Jubouri
Ovulation detection through salivary levels of sialic acid and glycosaminoglycans. Rand M. Al-khafagy,
66 Sahar H. Al-Ani, Ali Y.Majid
Temporomandibular disorders in association with stress among students of sixth grade preparatory
70 and students of fifth year high schools. Toka T. Alnesary, Rafil H. Rasheed
Histological evaluation of osseointegration around titanium implants in thyroidectomized rabbits

75 (experimental study). Zaid Muwafaq Ali, Nada Mohammed Hasan Al-Ghaban
Prevalence of pulp stone (Orthopantomographic-based). Zainab H. Al-Ghurabi, Areej A. Najm

80
Oral and Maxillofacial Surgery and Periodontology

Evaluation of the haemostatic action of povidone- iodine in dental extraction (Clinical and follow up
85 prospective study). Ali Qays Lilo Al-Amiri
A comparison between the antibacterial and antifungal effects of chlorhexidine digluconate (An in
88 vitro study). Firas H. Qanbar
Orthodontics, Pedodontic, and Preventive Dentistry

Effect of in-dental clinic bleaching agents on the releases of mineral ions from the enamel surfaces in
91 relation to their times intervals. Afnan Al-Shimmer, Mohammad Al-Casey
Physicochemical characteristic of unstimulated and stimulated saliva with different chewing gum
94 stimulation. Alhan A. Qasim, Eman K. Chaloob.
Dynamic lip to tooth relationship during speech, posed and spontaneous smile using digital
99 videography. Ali S. Al-khafaji, Nagham M. Al-Mothaffar
Dental caries in relation to oral infections and feeding types among children aged 2-5 years. Aseel
104 Haidar M.J. Al-Assadi
The staining effect of chlorhexidine mouthwash on non metallic brackets (An in vitro comparative
109 study). Hayder J. Attar, Fakhri A. Ali
Tooth attrition patterns in a group of Iraqi adults sample with different classes of malocclusion (A
114 comparative study). Issam M. Abdullah, Ausama A. Al- Mulla
Clinical significance of sella turcica morphologies and dimensions in relation to different skeletal
120 patterns and skeletal maturity assessment. Kasim A. Obayis, Ali I. Al-Bustani
iii
Clinical performance comparison of a clear advantage series II durable retainer with different
127 retainers' types. Mustafa M. Al-Khatieeb
Stimulation of rabbit condyle growth by using pulsed therapeutic ultrasound (A radiographical and
137 histological experimental study). Mustafa A.Qaisi, Nidhal H. Ghaib
The relation between W angle and other methods used to assess the sagittal jaw relationship. Sara M.
144 Al-Mashhadany
A comparative study evaluating the microleakage of different types of restorative materials used in
150 restoration of pulpotomized primary molars. Zainab A. Al-Dahan, Aseel I. Al- Attar, Huda E.A. Al-
Rubaee
Oral health status among a group of pregnancy and lactating women in relation to salivary
155 constituents and physical properties (A comparative study). Zinah M. Taqi Issa, Sulafa K.El-Samarrai
iv
Instruction for the Authors
The Journal of the College of Dentistry accepts manuscripts that address all topics related to
dentistry. Manuscripts should be prepared in the following manner:
Typescript. Type the manuscript on A4 white paper, with page setup of 2.5 cm margins. Type the
manuscript with English language font Times New Roman and the sizes are as follows:
1) Font size 18 and Bold for the title of the manuscript.
2) Font size 14, Bold and capital letters for the headings as ABSTARCT, INTRODUCTION,
MATERIALS AND METHODS, RESULTS and REFERENCES.
3) Font size 12 Bold and italic for the names and addresses of the authors ex. Ahmed G. Husam
4) Font size 11 for the legends of the tables and figures.
5) Font size 10.5 for the text in the manuscript.
6) Font size 10 for the text inside the tables.
7) Font size 9 for the references at the end of the manuscript.
Use single spacing throughout the manuscript and numbering of the pages should be in the lower
right hand corner.
Title of the manuscript:
The title should be written with a capital letter for the first word as (Effect of the retention and
stability….etc).
Abstract and key words. The abstract should contain no more than 250 words. The abstract should be
divided to the following categories: Background: (It contains a brief explanation about the problem
for which the research was done as well as the aim of the study), Materials and methods:, Results:,
and Conclusion:. Below the abstract, write 3-5 key words that refer as close as possible to the article.
The abstract should be written by the font Century Gothic size 8.
Text. The body of the manuscript should be divided into sections preceded by the appropriate major
headings (INTRODUCTION, MATERIALS AND METHODS, RESULTS and REFERENCES)
which are written in bold and capital. Minor headings should be typed in bold and subheadings should
be not bold but underlined.
References. References are placed in the text using the Vancouver system (Numbering system).
Number references consecutively in the order in which they are first mentioned in the text. Identify
references in the text, tables, and figures by Arabic numerals, and place them in parentheses within the
sentence as superscription ex. (2).
Use the style of the examples given below in listing the references at the end of the manuscript:
Book
1. Hickey JC, Zarb GA, Bolender CL. Boucher’s prosthodontic treatment for edentulous patients. 9th
ed. St. Louis: CV Mosby; 1985. p.312-23.
Journal article
4. Jones ER, Smith IM, Doe JQ. Occlusion. J Prosthet Dent 1985; 53:120-9.
Tables. All tables must have a title placed above the table. Identify tables with Arabic numbers (e.g.
Table 1). The tables should be done with a width of no more than 8 cm.
Figures and illustrations. All figures must have a title placed below the figure. Identify figures with
Arabic numbers (e.g. Figure 1). The figures should be done with a width of no more than 8 cm.
The article should not exceed 7 pages. The author should submit three copies of the article (one
original and two copies) and a (CD) containing the article.
v
J Bagh College Dentistry Vol. 24(2), 2012 Effect of different metal
Effect of different metal surface treatments and

thermocycling on shear bond strength of heat cure and
light cure at Co/Cr and Ni/Cr interface
Ali M. Khursheed , B.D.S. (1)
Salah A. Mohammed, B.D.S., M.Sc. (2)
ABSTRACT
Background Optimum bond strength at the metal – resin interface of prosthesis is essential for the success of that
prosthesis. The junction between metal alloy and acrylic resin is an area of clinical concern .Failure of a R.P.D. may
be linked to this interface. The main objective of this study were to determine the effect of different metal surface
treatment and thermocycling on the shear bond strength of Co/Cr alloy and Ni/Cr alloy to heat cure acrylic resin
and light cure acrylic resin.
Materials and methods: 120 metal samples were prepared, 60 Co/Cr samples and 60 Ni/Cr of square flat plate (30
mm x 30mm x 2 mm) that incorporated a central area (8mmx 12mm) of a large retentive mesh to simulate denture
framework. The samples were cleaned, finished and electropolished. Sixty samples of each type of metals were
divided into two groups according to the type of acrylic resin received each one 30 samples (A and group C) for
heat cure, B and group D for light cure) which were furtherly subdivided according to the type of surface treatment
into 3 subgroups each one 10 samples(A1 ,B1 ,C1and D1 )for no surface treatment, no thermocycling as a control
group (A2, B2 ,C2 and D2 )for Metal Prime II application with thermocycling (A3, B3 ,C3 and D3) for combination of
Air Abrasion and Metal Primer II application with thermocycling. The acrylic block were then prepared as a
rectangular block(12mm length ,8 mm width ,6 mm high )that was placed on a central area of metal plates, the
acrylic was fabricated in the same conventional way of denture construction. All the sample were mounted on
specially test fixture that would hold them rigid at a 90-degree angle from the horizontal plane of the crosshead of
the Instron machine .A tangent shear force was created by applying vertical load to the specimen .All of the
specimen were tested with Instron machine using stainless steel chisel shaped road at a constant crosshead speed of
5 mm min until failure of the bond occurred The specimen were stressed to failure .The force of bond failure was
recorded in Newton, which was divide by the surface of the bonded area (96 mm2 )to obtain the shear bond
strength calculated in Mpa.
Result: The results showed that the subgroup that received no surface treatment and without thermocycling for both
two type of resins heat cure and light cure (A1, B1, C1and D1) had the highest shear bond values, followed by
subgroups that received Air Abrasion + Metal Primer II surface treatments and thermocycling (A3, B3, C3,
D3).Subgroups that received Metal Primer II alone (A2, B2, C2 and D2) showed the least shear bond value than the
other subgroups.
Conclusion: All metal samples of Co/Cr and Ni/Cr with heat cure acrylic resin showed higher SBS mean values than
that light cure resin whether with surface treatment and thermocycling or without thermocycling concluded higher
binding of heat cure acrylic resin with the metal surface.
Keywords: Co/Cr-heat and light cure resin interface, Ni/Cr- heat and light cure resin interface ,metal surface
treatment,shear bond strength. (J Bagh Coll Dentistry 2012;24(2):1-5).
INTRODUCTION The actual bonding mechanism of metal to resin

The bond strength of the metal-resin interface framework has had many recent modifications
of a prosthesis it is a key factor in determining with three basic systems used (1-3). (1)
the serviceability of that prosthesis (1). The bond Mechanical Retention System; this system is
between the metal surface of a prosthesis subdivided into; (a) Macromechanical retention
framework and the acrylic denture base that it system retention which involves different
supports has been a concern of clinician, if there techniques (retentive element technique, pitting
is separation between these two materials, corrosion technique); (b) Micromechanical
especially at the junction referred to as the retention system which involves (air particle
external finishing line, the crack in that area abrasion, electrolytic etching and chemical
become a haven for microorganisms and plaque etching. (2) Chemical retention system which is
accompanied by staining. So a stable bond applied through (oxidation technique, tin plating
between the metal and resin should exist to and adhesive agents).
prevent microleakage and subsequent (3) Mechanical/Chemical retention system this
unfavorable results. system was achieved by a combination of
mechanical and chemical retention techniques ,the
(1) MSc student, Department of Prosthetic Dentistry, College of most widely used technique in this system is
Dentistry, Baghdad University silicoating technique which produced several
(2) Assistant Professor, Prosthodontic department, College of systems other than conventional silicoater
Dentistry, Baghdad University
Restorative Dentistry 1
including (Silicoater MDSystem, Rocatec System type of surface treatment that will be performed.
and Kevloc System (4) .This study was designed to A group of 40 samples (A1,B1,C1,D1) receive no
evaluate the effect of different types of metal surface treatment and no thermocycling for
surface treatments on shear bond strength of two controlling purposes .Another 40 samples (A2,
types of acrylic resins (heat cure and light cure). B2,C2, D2) were subjected to metal primer II
Metal Primer II (GC Corp, Tokyo, Japan), which pretreatment and thermocycling ,the last 40
contains a special functional monomer samples were subjected to a combination of air
methacryloyloxyalkyl thiophosphoric abrasion and Metal Primer pretreatment with
methacrylate (MEPS) which promotes bonding by thermocycling (A3, B3 ,C3,D3).
penetrating the metal alloy due to presence of Application of acrylic resin to grouping
phosphate group that presents chemical bonding samples
with the surface layer of oxide of chrome formed The metal samples receiving HCR, a special mold
in the surface of Co/Cr, which can reliable to was made from brass to reproduce the wax pattern
promote better union of with metal, in addition, which were rectangular block (12mm length
Metal Primer II forming co-polymerizing with the ,8mm width ,and 6 mm height ) ,the wax was
resin to produce both a mechanical and chemical melted in a small stainless steel container by using
bond to metal surface (5-6) . electrical thermo- mat at 10 degree and poured
inside metal mould ,then these block were sealed
MATERIALS AND METHODS in the central area of metal sample ( 8mm X
120 samples were prepared by using metal mold 12mm) .The conventional flasking procedure for
constructed and designed to reproduce wax acrylic denture construction was followed , for the
patterns with modeling sheet wax( Dentaurum, second subgroups; after wax elimination and
Germany ) which was a rectangular plate (30 mm before packing of acrylic resin, 2-3 drops of Metal
X 30 mm X 2 mm) that incorporated a central Primer II were dispensed into a dappen dish or
area (8mm X 12mm). On the upper surface there similar container, and then applied as a thin layer
is a metal handle which facilitate holding of the to the central mesh area of metal sample. The
mold during wax patterns procedure. The wax acrylic resin was applied to the treated surface
pattern was sprued ,investd (Rema R Exakt, after 5 seconds according to manufacturers
Dentaurum, Germany) and cast in Cobalt- instructions.
Chromium alloys (Remanium R Gfh, Dentaurum,
Germany),and Nickle-Chromium alloys (CB
BLANDO 72 ,Hatakeyama Dental MFG, Japan
).Each sample was cleansed from investment
material and electropolished for 12 minutes to
produces samples with a brilliant finished surface
Figure 2: Application of metal primer to

metal sample which received heat cure
acrylic resin
For third subgroups, the sample was treated first

with air abrasion by using laboratory air abrasive
blaster with 250 µm aluminum oxide at air
pressure of 4 to 6 bar for 1 minute, the samples
Figure 1: Finished and electropolished metal were held with a specially designed fixture for
samples standardization of the distance between the metal
surface and the nozzle of the device (20 mm),all
This study consisted of 120 samples prepared by the metal samples that receive HCR were trimmed
divided into two groups according to the type of ,smoothed and polished.
metal used .Group {A}&{C} refers to the metal The metal samples receiving VLCR were
samples that will receive heat-cure clear acrylic treated with a chemical bonding agent that was
resin(HCR), while group {B}&{D} refers to applied by brush to the central area of the metal
metal samples that will receive light cure acrylic samples which are now ready for light cure resin
resin(VLCR). Samples of each group were then application, it was directly applied resin to metal
furtherly subdivided into three groups; each one sample .No flasking procedure is needed.
consists of 10 metal samples, according to the
Each sample was thermocycled for 3000 cycles in

distilled water each cycle at 5°C to 50°C with a
dwell time of 1 minute, the 3000 cycles were done
within 10 days by divided the thermocycling
procedure into 300 cycles per day, all the sample
were mounted on specially test fixture that would
hold them rigid at a 90-degree angle from the
horizontal plane of the crosshead of the instron
machine
A tangent shear force was created by applying
Figure 3: Finished Metal Samples with Heat
vertical load to the specimen .All of the specimen
Cure Acrylic Resin (Group A ,C).
were tested with instron machine using stainless
steel chisel shaped road at a constant crosshead
speed of 5 mm min until failure of the bond
The specimen were stressed to failure .The
force of bond failure was recorded in Newton,
which was divide by the surface of the bonded
area (96 mm2 )to obtain the shear bond strength
calculated in Mpa.
Figure 4: Application of Metal Primer II for

Light Cure Acrylic resin
For the light cure acrylic resin the sheets of

acrylic are ready to apply directly without any
preparation or mixing like heat cure acrylic resin.
For the curing of light cured specimens a special
glass mould (12cm ×12cm) contains the same Figure 6: The vertical load applied using
dimensions and angulations of the rectangular stainless steel chisel shaped rod
block was designed The glass mould contains
rectangular block and has two glass covers upper RESULTS
and lower in order to permit for two sided curing The result of this study were collected and
in the light curing device and perforated with four analyzed statistically. Mean, standard deviation,
openings for the tightens of the two glass covers minimum and maximum values of shear bond
with metals bolts in order to provide firm pressure strength in Mpa of all groups are presented in
during curing, the metal bolts were placed in their tables 1&2.
position and then they were tightened by using Source of differences was investigated by further
wrench and tightened for only one click for complement analysis of data (Least Significant
standardization. Difference, LSD test) to examine the difference
After adaptation of light cure acrylic, then cured between difference pairs of the three groups as
with light cure unit (Yeti-Dental, Germany) at 400 shown in Tables 3&4 , where group {A}&{C}
to 500 nm wave length for 10 minutes {as refers to the metal samples that will receive heat-
manufacturer instructions} and After cure clear acrylic resin, while group {B}&{D}
polymerization, the samples were trimmed, refers to metal samples that will receive light cure
smoothened and then polished. acrylic resin. Samples of each group were then
furtherly subdivided into three groups; each one
consists of 10 metal samples, according to the
type of surface treatment that will be performed.
A group of 40 samples (A1,B1,C1,D1) receive no
surface treatment and no thermocycling for
controlling purposes .Another 40 samples (A2,
B2,C2, D2) were subjected to metal primer II
pretreatment and thermocycling ,the last 40
samples were subjected to a combination of air
Figure 5: Light cure Acrylic Resin (Group B,
D) after Curing
abrasion and Metal Primer pretreatment with samples of Heat cure Acrylic Resin-metal
thermocycling (A3, B3 ,C3,D3). interface, because the effect of air abrasion raised
mean bond strength values than that of only metal
DISCUSSION primed subgroup , the effect of the Air Abrasion
In the present study, shear bond strength of metal- on the bond of metal to resin could be explained
resin interface was evaluated , the specimen were that when the particles of Air Abrasion hit the
held at 90 degree so that the direction of the force metal surface and their kinetic energy is
applied to the specimen was vertical. All of the transformed to thermal energy, which may reach
specimen were tested with instron machine using the melting point of metal alloy. The melting of
stainless steel chisel shaped road at a constant the metal alloy is limited to 1 or 2 µm from the
crosshead speed of 5 mm min until failure of the surface.
bond occurredAll the specimens were prepared
using standard laboratory methods commonly Effect of Different metal Surface Treatments
used for clinical prosthesis and the specimen on SBS for Light cure Acrylic Resin-Metal
groups that received no more than the interface
conventional macromechanical retention system This study show that the SBS mean values of
which represented by the large mesh and without metal primed and thermocycled of the Light Cure
thermocycling, was prepared as control group Resin-Metal interface less than subgroup that
Many studies showed that there is an increase in were not subjected to surface treatment and
the bond strength of the metal resin interfaces without thermocycling Since thermocycling cause
when the alloy is treated with various metal hydration of the specimens, so this will leads to
surface treatments decreasing the shear bond strength after
thermocycling, Also, the water sorption of VLC
Effect of Different metal Surface Treatments were found to be greater than that of the other
on SBS for Heat cure Acrylic Resin-Metal types of acrylic resin, so the material absorbed
interface water and this had a damaging effect on the
This study shows that the SBS mean values of bonding.
metal primed and thermocycled of the Heat Cure This study also show that the SBS mean values of
Resin-metal interface less than subgroup that were metal primed ,air abraded and thermocycled
not subjected to surface treatment and without samples of the Light Cure Resin-metal interface
thermocycling ,this results may be explained by less than subgroup that were not subjected to
the reaction with water, such as swelling of the surface treatment and without thermocycling ,yet
acrylic resin due to water sorption, stresses it was higher than metal primed and thermocycled
resulting from the difference in the coefficient of samples of Heat cure Acrylic Resin- metal
thermal expansion, thermocycling speed up the interface subgroup, because the effect of air
diffusion of water in between resin and metal, abrasion raised mean bond strength values than
Metal Primer II (chemical bonding agent) that of only metal primed subgroup,this might be
increased SBS between the metal and both two due to the result of the combination of
types of acrylic resins (heat and VLC). Metal micromechanical retention that was achieved by
Primer II (GC Corp, Tokyo, Japan), which the Air Abrasion and chemical retention that was
contains a special functional monomer achieved by the Metal Primer II which provided
methacryloyloxyalkyl thiophosphoric adhesive bridges between the metal surface and
methacrylate (MEPS) which promotes bonding by resins (heat cure or VLC resins), the effect of the
penetrating the metal alloy due to presence of air abrasion on the bond of metal to composite
phosphate group. This group presents chemical resin could be explained by increasing the surface
bonding with the surface layer of chrome oxide area of alloy surface ,expanding the energy of the
formed in the surface of Co/Cr, which is reliable alloy and also highest the activity of the surface of
to promote better union with metal, in addition, alloy. The effect of air abrasion particle results in
Metal Primer II lead to co-polymerization with deposition of molecular coating of alumina and
the resin to produce both a mechanical and silica on the metal surface.
chemical bond to metal surface ,also this study Air Abrasion with aluminum oxide on the surface
show that the SBS mean values of metal primed of cobalt-chromium alloy favors the bonding
,air abraded and thermocycled samples of the between the chrome oxide and resin. Moreover,
Heat Cure Resin-metal interface less than Air Abrasion promotes formation of surface
subgroup that were not subjected to surface irregularities on the metal, achieving micro-
treatment and without thermocycling yet it was mechanical bonding when resin flows through
higher than metal primed and thermocycled these irregularities.
4. Pesun S, Mazurat R. Bond strength of acrylic resin to

REFERENCES cobalt-chromium alloy treated with the silicoater MD
1. Sharp B, Morton D, Clark A.E. Effectiveness of metal
and Kevloc systems. J Can Dent Assoc 1998; 64:798-
surface treatments in controlling microleakage of the
802.
acrylic resin-metal framework interface. J Prosthet
5. Freitas AP, Francisconi PAS. Effect of a metal primer
Dent 2000; 84:617-622.
on the bond strength of the resin-metal interface. J
2. Ohkubo C, Watanabe I., Hosoi T, Okabe T. Shear
Appl Oral Sci 2004; 12(2):113-6.
bond strengths of polymethyl methacrylate to cast
6. Silveria de Araujo C, Incerti Da Silva T, Ogliari FA,
titanium and cobalt-chromium frameworks using five
Meireles SS, Piva E, Demarco FF, Microlekage of
metal primers. J Prosthet Dent 2000; 83:50-7
seven adhesive system in enamel and dentine. J
3. Kim JY, Pfeiffer P, Niedermeier W. Effect of
Contemp Dent Pract 2006; 5(7):26-33.
laboratory procedures and thermocycling on the shear
bond strength of resin-metal bonding systems. J
Prosthet Dent 2003; 90:184-9.
Table 1: Mean Shear bond strength (SBS) of subgroups samples at Heat Cure Resin-metal
interface (Group A&C)
Statistical
A1 A2 A3 C1 C2 C3
Analysis
Mean 5.9 4.7 5.1 4.8 4.1 4.1
SD 1.05 0.9 0.8 1.1 1.3 1.1
Min 4.6 3.4 3.9 2.4 2.4 2.22
Max 7.62 6.1 6.3 6.4 6.1 6.17
Table 2: Mean Shear bond strength (SBS) of subgroups samples at Light Cure Resin-metal
interface(Group B&D)
Statistical
B1 B2 B3 D1 D2 D3
Analysis
Mean 4.6 3.3 3.5 3.8 2.7 3.1
SD 0.9 0.9 1.3 0.7 0.9 0.6
Min 2.8 2 2 2.6 1.6 2.1
Max 6.4 4.8 6.4 5.1 4.6 4.1
Table 3: Least significant difference for the Subgroups samples of Heat Cure resin-metal
interface (Group A&C).
(I) (J) P
(I-J)
Group Group value Significance
A1&A2 1.148 .014 S
A1&A3 .7244 .110 NS
A2&A3 -.424 .342 NS
C1&C2 .65100 .247 NS
C1&C3 .6130 .275 NS
C2&C3 -.0380 .945 NS
Table 4: Least significant difference for the Subgroups samples of Light Cure resin-metal
(Group B&D).
(I) (J)
(I-J) P value
Group Group Significance
B1&B2 1.33 .01 S
B1&B3 1.13 .03 S
B2&B3 -.19 . 69 NS
D1&D2 1.0 .00 HS
D1&D3 .76 .03 S
D2&D3 -.31 .36 NS
J Bagh College Dentistry Vol. 24(2), 2012 Comparison of certain
Comparison of certain mechanical properties including

deflection fatigue resistance of Cobalt Chromium alloy &
Nylon tooth colored clasping materials
Azhar I.M. Al-Awady, B.D.S., H.D.D., M.Sc.(1)
Widad Abdul-Hadi Al-Nakkash, B.D.S., H.D.D., M.Sc. (2)
ABSTRACT
Background: This study was conducted to test & compare the mechanical properties including the ultimate tensile
strength, yield strength, modulus of elasticity, ductility & deflection fatigue resistance of Cobalt Chromium alloy
samples, Flexite Supreme samples & commercially available Nylon samples, thus evaluating efficiency & life time
expectancy of these materials.
Materials and methods: A reproduction mold was made from addition silicon reproduction material to produce wax
patterns of standardized measures, these sacrificial patterns were used to produce fifty samples of each of the three
materials (a total of 150 samples). These specimens were tested by tensile testing machine and deflection fatigue
resistance machine.
Results: The tested materials expressed differences in their mechanical properties that were highly significant in all
comparisons.
Conclusions: Cobalt Chromium alloy, aside from its poor aesthetic, performs better in shallow deflection and have a
reasonable life expectancy. Flexile supreme is more aesthetically acceptable, with better performance and longer
life expectancy. Commercial nylon is with poor quality rendering it unusable.
Keywords: deflection fatigue, tensile strength testing, Cobalt Chromium, Flexile supreme. (J Bagh Coll Dentistry
2012;24(2):6-10).
INTRODUCTION These materials generally replace the metal, and

The removable partial denture must have retention pink acrylic denture used to build the framework
to resist reasonable dislodging forces. Primary for standard removable partial dentures (4). A
retention of a removable partial denture is nylon that is suitably stiffened could be extremely
accomplished mechanically by placing retention useful in the treatment of those patients for whom
elements on the abutment teeth (1). acrylic prostheses are not suitable. This would
A direct retainer is any unit of a removable dental include patients who demonstrate repeated
prosthesis that engages an abutment tooth in such fracture of dentures and those that show tissue
a manner as to resist displacement of the reactions of a proven allergic nature (5). Flexite
prosthesis away from basal seat tissue. This may Company developed and patented the firs tooth
be accomplished by frictional means, by engaging color clasps known. This product made of a nylon
a depression in the abutment tooth, or by material (6).
engaging a tooth undercut lying cervically to its Fatigue testing which is subjecting a test sample
height of contour (2). to rapid cycling at a given stress until failure
There are two basic types of direct retainers. One occurs is considered one of the basic testing
is the intracoronal retainer, which is cast or procedures used to provide data for metals and
attached totally within the restored natural alloys comparison (7), in addition fatigue is
contours of an abutment tooth. The other type of a responsible for 90% of all service failure (8). The
retainer is the extra coronal retainer, which uses retentive clasp arms are the parts of removable
mechanical resistance to displacement from partial denture most frequently damaged (9,10)
components placed on or since clasps in clinical use are subjected to cyclic
attached to the external surface of an abutment bending during insertion, removal of partial
tooth (1). The extra coronal or clasp direct retainer dentures and also during mastication (7).
is used more frequently than attachment (3).
The problems of clasp arm include poor aesthetics MATERIALS AND MTHODS
and fracture of clasp arm (1). The application of Tensile strength test: an analog of the specific
nylon like materials in the fabrication of dental shape and dimensions of the sample required
appliances has been seen as an advance in dental (according EN.ISO. 527-2: 1993) was made from
materials. galvanized steel and used for molding a silicon
mold to produce standardized wax patterns from
(1) Head of the prosthetic department of specialized center of which samples were made. Thirty samples were
dentistry, Thi Qar, An-Nasirya. dedicated for this test. Ten samples of Flexite
(2) Professor, department of Prosthetic dentistry, college of
dentistry university of Baghdad. supreme; group A (Flexite USA) & ten of
commercial nylon; group B (made in China) were Deflection fatigue resistance test: the same
injected using a thermoplastic injection system procedures for the production of samples were
(KCX-09A, China). The same wax patterns were followed to produce the 120 samples required for
used for casting ten Co-Cr samples. All Cobalt this test (40 samples of each material). The shape
Chromium samples were checked for unforeseen and dimensions of the samples were prepared
impurities that may have been hidden below the according to (ASTM E647/1988). The test was
outside surface (figure 1). The samples were
seated individually on the X-Ray machine
(Diamax Digivision, Planmeca, Finland) at a
distance of 10 cm. between the sample to be
tested and the radiographic cone was achieved
using the film holder. The X-Ray machine was set
to 70 KV, 10 MA and the exposure time was 0.6
seconds (11-13). All samples that are proven to have
air bubbles or cracks in the testing area (the area
of constriction & not the handles) were discarded.
Figure 2: A polymer specimen clamped by
the jaws of the testing machine after the test
is over by failure in tension.
Figure 1: Cropped picture showing a void in

the testing area of the sample. Samples
showing a defect under X-Ray were
discarded.
The nylon samples were tested using a
tensile testing machine with jaws designed to grip
polymer samples (figure 2). The metal samples
were tested with a tensile testing machine with
Figure 3: A metal specimen clamped by the
jaws designed to grip metal samples (figure 3).
jaws of the testing machine after the test is
The test was completed by loading the samples till
failure in tension with a head speed of 20mm. per
over by failure in tension.
carried out by screwing the grip of the testing
sec. The values of the tensile strength were
machine (HSM20, HI-TECH EDUCATION,
calculated for each test specimen as the force at
England). The deflection values
failure divided by the cross sectional area
(0.25mm.;0.5mm.; 1mm.; & 2.1 mm.) were
according to the following formula:
obtained from the monogram provided with the
(14)
manual of the machine. In a dental appliance,
Tensile strength = F (N.) / A (mm.²) stress reversal is unlikely to occur & the structure
will be stressed in one direction & allowed to
F: Force at fracture return to zero in each cycle (15) & (16) & in this
A: Original cross-sectional area (ASTM study, this stress cycle was used. Each sample was
specifications D-638 M, 1986). marked in the center of its length. The deflections
The modulus of elasticity (E), were determined of 0.25mm, 0.5mm, 1mm. and 2.1mm were
using the method of comparing two different measured at this point for all the samples by a dial
points on the stress strain curve and then applying gauge with an extended spindle whose tip was
the following formula: applied to the central point in the upper surface of
the sample (13) & (17). After a sample had been setup
E= δ2- δ1/ Ɛ2- Ɛ1 (14)
in the testing machine, the sample was fatigued
δ1: stress on the first point until fracture or permanent deformation occurred
δ2: stress on the second point (figure 4 & 5).
Ɛ1: strain on the first point
Ɛ2: strain on the second point
Figure 4: Samples showing cracks in the area

to be tested.
Figure7: Stress strain curve of test group A

(Flexite supreme) samples under tension.
Figure 5: Propagation of a crack leads to an

eventual sample fracture.
RESULTS
Stress strain curves of the materials were plotted Figure 8: Stress strain curve of test group B
demonstrating the behavior of the tested material (commercial Nylon) under tension.
in tension and as follows:
1. Co-Cr alloy is stiff, brittle but strong (figure For the ultimate tensile strength, yield strength
6). and modulus of elasticity Co-Cr had the highest
mean values, respectively: 614.14 MPa;
337.84MPa &120.794MPa. While for the
Stress elongation of breakage it had the lowest mean
MPa value of 9.83 %.
For the ultimate tensile strength, yield strength
and modulus of elasticity Flexite supreme had the
following mean values respectively: 152.2MPa;
148.17MPa & 10.4778 MPa. While for the
elongation at breakage it had the highest mean
value of 198%.
For the ultimate tensile strength, yield strength
Strain % and modulus of elasticity the commercial nylon
had the lowest mean values, respectively:
Fig. 6: Stress strain curve of the mean value 45.81MPa; 34.73MPa & 5.6153MPa. While for
of (Co-Cr) samples under tension. the elongation at breakage it had the lowest mean
2. Flexile supreme: flexible, ductile and strong value of 173.64 %.
(fig. 7). Multiple group comparisons of mechanical
properties:
3. Commercial nylon: stiff, ductile and weak (fig. By conducting Fisher's least significant difference
8). test (LSD), to obtain an understanding of the
multiple statistical comparisons among groups.
The results were found to be as follows:
When comparing the Co-Cr with Flexite supreme
test group for yield strength, ultimate strength,
modulus of elasticity and elongation at breakage
the results revealed a statistically high
significance.
Comparing Co-Cr with commercial Nylon elasticity the results revealed a statistically highly
test groups for yield strength, ultimate significant, and as shows in the (table 1).
strength, modulus of elasticity and
elongation at breakage the results revealed a DISCUSSION
statistically high significance.
1. Mechanical properties: The Co-Cr
group registered E & yield strength, which are a
Table 1: Fisher's least significance difference poor feature concerning clasp design (18). While
(LSD) analyzing multiple comparisons between the Flexite supreme registering yield strength and
groups modulus of elasticity that are lower than those of
Mean
Std. Error Sig.
Co-Cr and higher than that of the commercial
Difference nylon , they might represent the ultimate choice of
Co- A 189.67000* .86026 .000 * a material that can flex out of deeper undercut
Yield Cr B 303.11000* .86026 .000 ;thus minimizing the amount of tooth preparations
Strength
A B 113.44000* .86026 .000 and the otherwise un necessary loss of healthy
.Ultimate Co- A 461.94000* .57241 .000 tooth structure, enhancing retention of a
Tensile Cr B 568.33000* .57241 .000 removable partial denture & minimizing the
strength A B 106.39000* .57241 .000 amount of stress excreted on the abutments .The
Co- A 110.31620 *
.29820 .000 amount of stress required to produce the
Modulus of Cr necessary retention in Flexite Supreme Nylon
B 115.17870* .29820 .000
elasticity
A B 4.86250* .29820 .000 clasps is delivered through the increase of bulk of
Co- A -188.17000-* .41083 .000 the clasp, noting that such an increase wouldn't
Elongation Cr B -163.81000-* .41083 .000 overload the prosthesis weight; hence Nylon low
A B 24.36000* .41083 .000 density compared to most base metal alloys; nor
LSD *. The mean difference is significant at the 0.05 level. affect the aesthetics of the patient; hence the tooth
colored or gingiva colored clasp. The commercial
nylon (made in china) proven to be not functional
Table 2: mean value of cycles required to because of the weakness of the material , and
fracture or permanently deform a sample. lower modulus of elasticity which would require
0.25 mm. 0.5 mm. 1 mm. 2.1 mm. building a clasp of non acceptable bulk to
Material
deflection deflection deflection deflection
A 21272587.5 12128790.7 7818114.4 3193095
compensate for its inherent weakness and
B 18795881.1 10673335.7 6108554 3045619.7 generate enough strength to retain a RPD (19).
Co-Cr 32210.4000 13346.9 865.7 527.6 This behavioral difference between metal and
polymer could be attributed to the difference in
the microstructure level. Metals have small
building blocks that are well arranged and highly
organized in a dense uniform pattern thus give a
rather predictable mechanical behavior in
temperatures lower than that of melting point,
while that are made up of large strains of polymer
molecules, the smaller molecule of polymers can
be thousands of times larger than that of any
naturally occurring molecules of metal alloys.
Figure 9: A histogram demonstrating a Plus the fact that polymers have different sizes of
comparison of the mean values of the molecules contributing to its' structure. These
number of cycles required to fracture or building blocks of polymers are arranged as areas
deflect a sample under deflection for the (Co- of well organized molecules (the crystalline state)
Cr) , test group A (Flexite supreme ) and test surrounded by areas of curved, twisted &
group B (Commercial Nylon). entangled polymer molecules (amorphous state).
The amorphous state is responsible for the
Deflection fatigue resistance test results showed freedom in movement in any direction of the
that Flexite supreme had the highest mean value polymer in temperatures that are considerably
at all deflections while the Co-Cr had the lowest lower that the melting temp (20).
mean values and as shown in table 2 & figure 9. Deflection fatigue: The results of this study for
Comparing the two test groups for yield strength, Co-Cr alloy revealed that the possibility of having
a Co-Cr clasp that is subjected to cyclic bending
ultimate strength and elongation at breakage
without failure fracture is unlikely to take place
recorded a high statistical significance. even in the minimum deflection of 0.25mm which
Comparing the two test groups for modulus of is in agreement with previous clinical
observations (10) & other fatigue testing (14,21,7) & properties of commonly used denture base resins. J
(17) Prosthodont; 13:17-27.
. This can be attributed to the mechanical
7. Morris HF. Asgar K, Tillitson E. "stress relaxation
properties of the alloy, mainly the E. the proof
testing. Part 1: A new approach to the testing of
stress (yield strength) & the elongation values. To removable partial denture alloys, wrought wires- &
explain the results of this study, it seems clasp behavior". J prosthetic Dent 1981; 46(2): 133-
important that the E of the metals should be 41.
considered along with the yield strength (proof 8. Zavanelli R, Henriques G, Ferreira H, Almeida Rollo
stress) property (22). Co-Cr alloys have a high E J. "Corrosion fatigue life of commercially pure
Titanium & Ti-6Al-4V alloys in different storage
which is a poor feature concerning clasp design
environments". J Prosthetic Dent 2000; 84(3): 274-9.
but they do have a good proportional limit (18). 9. Brockhurst PJ. "A new design for partial denture
Retentive clasp arms are required to have circumferential clasp arms". Australian Dental Journal
adequate elasticity to deflect out of the retentive 1996; 41 (5): 317-23.
undercut, adequate stiffness to produce retention 10. Harcourt HJ. "Fractures of Cobalt-Chromium
&adequate strength to resist accidental damage castings". Br Dent J 1961; 1 10(2): 43-50.
(23) 11. Bates JF. "The mechanical properties of Cobalt-
. The other mechanical property that may affect
Chromium alloys & their Relation to partial denture
the fatigue resistance of a clasp is the ductility of design". Br Dent J 1965; 119 (9): 389-96.
the material which is usually expressed by the 12. Bates JF." Studies related to the fracture of partial
elongation values, the ductility of Co-Cr alloy is dentures. The functional strain in Cobalt Chromium
considered low (brittle material). Co-Cr clasps are dentures , a preliminary report". British Dental Journal
more likely to fracture if bent (24), also increased 1966;120; 79-83.
13. Vallittu PK. Luotio K. "Effect of Cobalt-Chromium
ductility of Co-Cr alloy improved the resistance to
alloy surface casting on resistance to deflection fatigue
fatigue (25). & surface hardness of Titanium". International Journal
Differences between the materials (Co-Cr of Prosthodontic 1996; 9 (6): 527-32.
alloy& Flexite supreme & commercial Nylon) 14. Craig RG. "Restorative Dental Materials", 12 ed.
in deflection fatigue. St Louis: Mosby, 2006; Ch 4: 61-4.
The difference in the behavior of the samples of 15. Earnshaw R. "Fatigue tests on dental Cobalt -
Chromium alloy". Br Dent J 1961: 110(10): 341-5.
the three materials at 0.25mm. & 0.5mm. D and
16. Preston JD. "Cobalt-Chromium-Titanium alloy for
the statistically high significance can be related to removable partial dentures". Int J Prosthodontics
the difference in mechanical properties, especially 1997;10(4): 309-17
the yield strength, which determines the amount 17. Bridgeman J.T. , Marker VA, Hummel SK, Benson
of stress that can build up in the sample (clasp) BW, Pace LL. "Comparison of Titanium & Cobalt-
when deflected. The high yield strength of Co-Cr Chromium removable partial denture clasps'! . J
Prosthetic Dent 1997; 78 (2): 187-93.
alloy means that the stresses generated due to
deflection can easily pass there proof stress to 18. Bates JF. "Retention of partial dentures". Br Dent J
cause damage or permanent deformation. While 1980; 149: 171-4.
the lower yield strength of the Flexite supreme 19. Kaplan 2008. Dentistry Today. Issue date: December
means that considerably lower amount of stress is 2008, “flexible removable partial denture, design and
generated that don't cause the material to fracture clasp concept".
20. Micheal Sepe. 2008. Ides Articles .Design. http://
or deform (26). www. Ides.com/articles/design/2008/Sepe_02_asp.
21. Asgar K. Peyton FA. "Flow & fracture of dental alloys
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84. Hamanaka H. "Fatigue resistance of Titanium-Nickel
3. R. John Davenport, Evelyn Strauss, and Kelly alloy cast clasps". Int J Prosthodontics 1997;10(6):
LaMarco" Aging Knowledge. Enviroment.", 3 October 547-52.
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4. Negrutiu M, Sinescu c, Romanu M, Pop D, Lakatos s study of CO-Cr Partial dentures fractured in service "J
(2005). Thermoplastic resins for flexible framework Dent 1984; 12(2); 122-6
removable partial dentures. Temisoara Med J; 55:295- 25. Vallittu PK. "Transverse strength, ductility &
99. qualitative elemental analysis of Cobalt-Chromium
5. Stafford GD, Huggett R, MacGregor AR, Graham J. alloy after various durations of induction melting". J
(1986): The use of nylon as denture base material. J Prosthodontic 1997; 6 (1): 55-60.
Dent.;14:18 26. Craig RG, O'Brien WJ. Powers JM. "Dental Materials:
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(2004). Evaluation of mechanical and thermal 1996; Ch 2:16-26; Ch 11 : 222-5.
J Bagh College Dentistry Vol. 24(2), 2012 A comparison of the retention
A comparison of the retention of complete denture bases

having different types of posterior palatal seal with
different palatal forms
Mayada Q. Abdul Khafoor, B.D.S, M.Sc. (1)
ABSTRACT
Background: The most common problem associated with the lack of retention of maxillary complete denture is faulty
posterior palatal seal pps. The methods for achieving a pps include arbitrarily scraping the cast, selective pressure
technique, and the physiologic impression technique.
Material and Method: In this study forces required to dislodge a maxillary complete denture bases were compared
for different types of posterior palatal seals (PPS) with different palatal forms by using a specially designed strain
gauge force tranducer and strain measuring device. Nine male and female subjects are selected with age range
55-70 years. These patients with different palatal forms according to House's classification of palatal forms: Class I flat,
Class II intermediate and Class III high. Using different impression technique the first ordinary impression with Zinc-
oxide eugenol and scraping the cast for pps, the second physiological impression by using korecta wax No.4.
Result: The results show very highly significant difference, between the different designs of pps and physiological
impression for each group.
Conclusion: The physiological impression of pps give better retention because no over compression of tissues (within
the physiological limit) and concluded that the form of palate has direct influence on the retention of complete
dentures and will aid in the selection of type of posterior palatal seal needed.
Keywords: Maxillary complete denture, posterior palatal seal. (J Bagh Coll Dentistry 2012;24(2):11-17).
INTRODUCTION
A well fitting and retentive complete maxillary - Provide a thicker posterior border to
denture requires a well fitting surface a peripheral compensate for processing shrinkage of the
border compatible with the muscles and tissues denture base in this area5, and
which make up the muco-buccal and muco-labial - Reduce discomfort when contact occurs
spaces so that a peripheral seal is created by the between the posterior border of the denture
soft tissues draping over them and finally, a and the dorsum of the tongue 4.
posterior palatal seal. Avants 1 has shown that "a The methods for achieving a pps of a maxillary
pps is necessary for optimum retention of complete denture include arbitrarily scraping the
maxillary complete dentures" and that of the cast prior to denture processing, the selective
designs he tested, none proved to be superior in pressure impression technique, and the
all of his five test subjects1. physiologic impression technique 6.
The pps area has been defined as an area of soft Winland and Young11 and Chen et al10 stated that
tissue along the junction of the hard and soft the most dental schools teach the method of
palate on which pressure, within the physiologic carving the pps arbitrarily in the maxillary cast.
limits of the tissues, can be applied by a denture This arbitrarily location and scraping of the
to aid in its retention 2. definitive cast was found to be the least accurate
The pps of a maxillary complete denture can be technique the effectiveness of pps of maxillary
established during the making of the final complete denture is confirmed only at the
impression by scoring the final cast, or by insertion appointment.
incorporating the seal in the finished denture base. The anterior vibrating line at the area of the
The technique can be classified generally as being junction of the hard and soft palate can be located
either functional or empirical 3. Regardless of the by palpation of the hamular process and the fovea
technique used or the stage of denture fabrication palatine. The anterior vibrating line serves as the
during which the pps is placed, the objective of its anterior border of the pps area. The posterior
utilization is the same. It provides aperipheral seal vibrating line lies in the junction of the
by selectively displacing soft tissue to 4: aponeurotic portion of the soft palate and
- Provide close tissue contact during speech and represents the posterior extension of the pps area,
swallowing, preventing food and debris from they considered a two separate lines of flexion 12.
impinging between the denture base and the The location and incorporation of the pps on the
underlying tissue. maxillary definitive cast are often done by the
- Enhance retention and stability. dentist or dental laboratory technician. However
these procedures should be the responsibility of
(1)Lecturer, Department of Prosthodontics, College of dentistry, the dentist, as the tissue displacement can only be
Baghdad University. determined clinically 13. A faulty pps may cause
poor retention and /or tissue irritation. Brian M et Antolinocolon et al 8 concluded that the form of
al 6 describe a technique for the location of the the palate has direct influence on the retention of
pps intraorally and accurate transfer to maxillary complete denture will aid in the selection of the
complete denture cast by indelible pencile. Laney type of posterior palatal seal needed.
and Gonzalez 14 discussed the need for knowledge
of the oral cavity's anatomy so that the static MATERIALS AND METHOD
surface of the denture base can be balanced A. The testing apparatus
against one dynamic tissue surface. In the pps For the purpose of this study, retention has
area, the tissues are displaceable and the degree of been expressed in term of force required to
displacement can be found by palpation with a vertically dislodge a maxillary complete
"T" burnisher 15, by closing both nostrils of the denture using a specially designed strain gauge
patient and having him blow gently 16 or by force tranducer. The data measured by gram 23.
visualizing the vibrating line as the patient says The apparatus consist of many parts as shown
"ah" 3. Also, by placing the tissues with various in figure 1.
impression materials, a functional or physiologic B. Selection of patients
pps can be impression made as early as the Nine edentulous patients were selected from
maxillary final impression 18. Another method, prosthodontic clinic, college of dentistry,
scraping the maxillary cast before final processing Baghdad University, 6 males and 3 females,
of the denture, can be used to construct a pps 19. the age range between 55-70 years, the criteria
Therefore, the pps takes on many various shapes, used for selection were relatively smooth, firm
size and locations. These various types of pps are alveolar ridge covered with healthy mucosa
discussed by winland and Young11, and their without any posterior under-cuts. The patients
construction as taught in our dental schools is with different palatal form according to
investigated. They discussed that no mather what House's classification of palatal forms: Class I
type of pps is used, the important word is seal-to flat palatal vault in the hard palate and Class
seal out air and food and to seal in partial pressure III a high vault and Class II intermediate
and they said that the determination of the between them 7,30.
posterior limit and palatal seal of the maxillary C. Impression techniques:
complete denture is not the technician's A preliminary impression with impression
obligation, but the responsibility of the dentist. compound (Quayle Dental, England) was
Abedalbaki et al 20 compare the retention of taken and 2 custom trays were fabricated on
complete denture bases with different types of pps the study model. Then two impression
(bead, double bead, and bufferfly). They found no techniques used:
design provide superior priority than the other I. First impression technique:
type of pps but a double beading and butterfly pps 1. Before the border molding procedure,
can improve the retention of a maxillary complete trim and adjust the posterior border of
denture. the custom tray 1 to 2 mm distal to the
Determinants of posterior extension: vibrating line.
During the final impression appointment, the 2. Complete the border molding and make
final extension of posterior border of the a final impression by using zinc oxide-
maxillary denture is determined. Factors to be eugenol (ZoE) paste.
considered include: 3. Remove the impression from the mouth.
- The drape of the soft palate in relation to the 4. Mark the vibrating line in the mouth
hard palate. A more abrupt relation between with indelible pencile by using "ah"
the hard and soft palates generally indicates sound with nose blowing and using the
increased muscular functional activity of the fovea palatinae in locating the vibrating
soft palate, thus reducing the potential line 24.
posterior extension of the palatal seal. 4 5. Reinsert the maxillary impression in the
The shape of palatal vault is related to the activity mouth and transfere the location of
of the soft palate. The flat vault has the least vibrating line to the ZoE impression.
movable soft palate and the widest area of 6. Poured with stone (Zeta, selensor,
displacable tissue. In contrast, the high vault or Industria Zingardi S,r,i, Italy). The
"V" shaped palate often has a soft palate virtually water to powder ratio recommended by
at right angles to the hard palate and is extremely the manufacturer was used.
mobile. Thus the area of tissue displaceability is 7. The master cast was then duplicated
very narrow. The intermediate palatal vault lies once by using heavy body silicon, the
between these two extremes 7,21.
master cast marked 2 while the to exert their displacing effect on wax,
duplicated cast was marked 3. there by achieving functional depth of
II. The second impression technique seal. Figure (2)
(Physiological posterior palatal seal). 8. Impression is carefully beaded and
1. The same steps 1, 2 and 3 used in the boxed and the impression then poured
previous technique. with stone (Zeta, Selensor, Industria
2. The anterior vibrating line can be Zingardi s.r.i Italy). The water powder
visualized by instructing the patient to ratio recommended by the manufacturer
say "Ah" with short vigorous bursts was used. This cast was marked 1.
while the posterior vibrating line can be D. Scraping the casts for incorporation of pps:
visualized by instructing the patient to The casts marked 2 and 3 were scraped to
say "Ah" in short bursts in a normal carve certain designs into their posterior
unexaggerated fashion, then mark the palatal areas. No. 4 round bur with a lacron
anterior and posterior vibrating lines in carver were used. The patients classified into
the mouth with indelible pencile and groups according to House's cassification of
transfer the location to the ZoE palatal form.
impression. Group A (Class I flat palatal form)
3. Kerr Korecta wax No. 4 was used to A1= physiological impression technique of
record the pps area, it’s a fluid, mouth pps
temperature wax, is preferred for this A2= scraping the cast 2 according to House-
procedure. It will flow sufficiently at modified butterfly 3-4mm wide and 1mm
mouth temperature to avoid over deep was carved in the center of the palatal
displacement of tissues. because the seal area passing through the hamular
wax continues to exhibit it property of notches and flushing out on approaching the
flow in the mouth, it permits the tissues buccal sulcus 26.
in the area of the pps to rebound, A3= Scraping the cast 3 –a single bead
establishing a degree of displacement design as described by boucher 25. A V
that is physiologically acceptable. This shaped groove 1mm deep and wide at the
wax is painting on pps area of base was carved; it passed to rough the
impression. hamular notches and flashed out approaching
4. Impression is reseated in mouth and the buccal sulcus.
held in place for about 3 minutes. Group B (Class II intermediate palatal form)
Patient is guided and instructed to tip B1= physiological impression technique of
head forward to approximately 30o from pps
vertical position and forcibly place B2= Scraping the cast 2 according to House-
tongue against tray handle or clinician's modified butterfly 2-3mm wide and 1mm
finger which is supporting tray, this deep was carved in the center of the palatal
maneuver allow pps area to be recorded seal area passing through the hamular
in functional position 4,22. notches and flushing out on approaching the
5. Excess wax will be displaced and will buccal sulcus 26.
flow posteriorly. B3= Scraping the cast 3-asingle bead design
6. Impression is removed and examined as described by Boucher 25, like A3 group.
wax that has flowed posterior to seal is Group C (Class III high palatal form)
removed with Bard-parker blades, C1= physiological impression technique of
intimate contact between wax and pps
tissues is indicated by glossy C2= Scraping the cast 2 according to House-
appearance of wax in contrast to dull single bead design 26 1mm width and depth
appearance where no contact exists. made on the posterior vibrating line.
Wax is painted on where indicated and C3= scraping the cast 3-abutterfly shaped
the impression is reseated intraorally configuration was carved as suggested by
until wax exhibits contact along entire Hardy and Kapur 3. An angled groove
posterior palatal area. 1.0mm deep and 1.5mm wide at the base was
7. After trimming excess wax, impression carved in the center of the palatal seal area
is reseated for five to eight minutes. passing through the hamular notches and
During this time, patient intermittently flushing out on approaching the buccal
repeats head and tongue positions. This sulcus Figure (3).
last seating allows tissues in area of pps
E. Construction of the test denture bases: The mean values of the statistical analysis for the
Identical denture bases for the pps were made data of group C (deep palatal form) between the
on cast 1, 2 and 3 for each group and were three groups C1, C2 and C3 as shown in Table
designated 1, 2 and 3 respectively. Base plate (5). The results of ANOVA table with LSD as
was formed for each of the casts using two shown in Table (6). The results explained that
mm thick layers of base plate wax, the bases there was a very highly significant difference
were processed using heat curing acrylic resin between groups and between groups (C1 and C3)
(Quayle Dental, England). and between (C2 and C3) groups. While a non
F. Clinical testing significant difference between (C1 and C2)
Astringe of about 1 inch length was secured groups.
on the polished palatal surface of each of the
maxillary denture bases in region relating to DISCUSSION
the second premolar and first molar teeth 14, An adequate seal of the posterior border of a
20
, with auto polymerizing acrylic assembly maxillary complete denture is essential for
(Figure 4). The dislodging force that is retention. Establishing the pps at final impression
directed to the maxillary denture bases was stage confirm the effectiveness of the pps and
applied at the middle of the denture base allows the dentist to control its location and the
where the middle location is considered the amount of tissue displacement 10,27. This is agree
most reliable region for testing the retention with the result of this study which revealed that
of complete maxillary denture 15. the physiological impression technique of pps
All tests for a subject were completed in one area give better retention for complete denture
appointment; all the denture bases for that subject base than the other technique of pps. Vintion 28
were stored in water for the same length of time stated, "where the tissues move in normal function
before being tested for retention. Thus, the time of is the area where maximum peripheral seal can be
day and water sorption was not variables. achieved with the least amount of tissue
The patient head was held firmly on the head rest displacement. This appears to be best
with occlusal plane parallel to the floor. Figure (5) physiologically. It is maximum result with
all measurements of retention involving in a given minimum activity 11.
subject were conducted at one sitting, each test The route of the vibrating line from one side of
denture base was subjected to three retention tests. the palate to the other is not of a definite pattern
The force values at which the denture base was but varies with the shape of the palate. This
dislodged completely from the palate at a steadily variation is such a constant observation that palate
increasing force was displayed on strain or throat forms have been classified as Class I,
measuring device represented by gram, the force Class II and Class III. Class I indicates a low, flat
values in grams could be calculated. vault in the hard palate which continues into a soft
palate that has a minimal amount of drop and
RESULTS movement. This situation permits a more distal
The mean values of the statistical analysis for the extension of the maxillary denture and provides
data of group A (flat palatal form) between the broader pps area 17. This agree with the result of
three groups of A1, A2 and A3 were shown in group A, it was found that the physiological
Table 1. Where as the results of ANOVA table impression technique and modified butterfly 3-
with LSD as shown in table 2. The results 4mm width for pps area give better retention than
explained that there was a very highly significant the single bead design of pps. Nikoukar 17 and
differences between the groups and between (A1 Swenson and Terkla 9 were found that the flat
and A2) and between (A1 and A3) and between palatal shape has vibrating line located farther
(A2 and A3) groups. While the mean values of the posteriorly.
statistical analysis for the data of group B While in Class III indicates a high vault in the
(intermediate palatal form) between the three hard palate and an acute drop and maximal
group B1, B2, and B3 as shown in Table (3). movement in the soft palate. The region where
Where as the result of ANOVA table with LSD as this acute drop occurs becomes extremely critical
shown in Table (4). The result explained that because it places greater limitations on the distal
there was a very highly significant difference extension of the maxillary denture and will
between groups and between groups (B1 and B3) accommodate only a narrow pps 17. This agree
and between (B2 and B3), while there was a non with the result of group (C) which revealed that
significant differences between groups (B1 and the physiological impression technique of pps and
B2). single bead design of House give better retention
for complete denture base than the butterfly shape
of pps (Hardy and Kapur) 3. Nikoukari 17, 10. Chen MS, et al. Methods taught in dental schools for
Swenson and Terkla 9 found that the higher the determining the posterior palatal seal region. J
Prosthet Dent1985; 53: 380-3.
vault the more abrupt and forward is the vibrating
11. Winland RD, Young JM. Maxillary complete denture
line. While the Class II designates those palatal posterior palatal seal: variation in size, shape and
forms which are intermediate between Class I and location. J Prosthet Dent 1973; 29(3): 256-61.
Class III 17. This agree with the result of group B 12. Vernie AF, Chitre V, Aras M. A study to determine
which revealed that the physiological impression whether the anterior and posterior vibrating lines can
of pps and modified butterfly 2-3mm width be distinguished as two separate lines of flexion by
unbiased observer: Apilot study Indian J of Dental
according to House give better retention for
Research 2008; 19(4): 335-9 [IVSL].
complete denture base than the single bead design 13. Winkler S. Essentials of complete denture
of pps (Boucher). prosthontics. 2nd ed. St. Louis: Ishiyaku Euro America;
The mucosal tissues of the pps area vary in 1994.
displaceability from patient to patient, the task of 14. Laney WR, Gonzalez JB. The maxillary Denture: Its
determining the shape, size and depth of the seal palatal Relief and posterior palatal seal. J Am Dent
Assoc 1967; 75: 1182-7.
must be accepted by the clinician and should not
15. Bylicky HS. Variable Approaches in obtaining a
be assigned to the Laboratory technician. It is posterior palatal seal: Description of Technique. NYJ
quite improssible to establish the posterior limit, Det 1966; 36: 280-2.
the width and depth of the seal in an edentulous 16. HeartWell GM, Rhn AO. Syllabus of complete
cast alone, and it is the clinician's responsibility to dentures. 1st ed. Philadelphia: Lea and Febiger
make the decision based on proper procedures in publishers; 1968.
17. Nikoukari H. A study of posterior palatal seal with
the mouth.
varying palatal forms. J Prosthet Dent 1975; 34: 605-
13.
18. House MM. Full Denture Techniques study club No.1,
REFERENCES 1950.
1. Avants WE. A comparsion of the retention of 19. Stephens AP. Upper full denture retention. J Irish Dent
complete denture bases having different types of Assoc 1968; 14: 131-2.
posterior palatal seal. J Prosthet Dent 1973; 29(50): 20. Mohammed AA, et al. Company required dislodging
484-93. forces between different types of posterior palatal seal.
2. Roland LE, Forrest RS. The posterior palatal seal. A Mustansiria Dent J 2006; 3(1): 97-101.
review. Australin Dent J 1980; 25 (4): 197-200. 21. Watt DM, Mac Greagor AR. Designing complete
3. Hardy IR, Kapur KK. Posterior border seal its dentures. Philadelphia: W.B. Saunders company;
rationale and importance. J Prosthet Dent 1958; 8(3): 1976. 83-6.
386-7. 22. Silverman SI. Dimension sand displacement patterns
4. Gerald SW. Establishing the posterior palatal seal of posterior palatal seal. J Prosth Dent 1971; 25: 470.
during the final impression procedure: a functional 23. Ilham HAA. The effect of three different denture
approach. J Am Dent Assoc 1977; 94: 505-10. adhesives on the retention of mandibular complete
5. Anthony DH, Peyton FA. Dimensional accuracy of denture (comparative study). A master thesis, College
various denture base materials. J Prosthet Dent 1962; of Dentistry, University of Baghdad, 2008.
12: 67-81. 24. Behnoush R, Vicki CP. Current concepts for
6. Brian W, Robert F. Accurate location of posterior determining the posterior palatal seal in complete
palatal seal area on the maxillary complete denture denture. J Proth Dent 2003; 12(4): 265-70.
cast. J Prosthet Dent 2006; 96 (6): 454-5. 25. Boucher CO. Swensons complete dentures. St. Louis:
7. Sudhakara VM, Sudhakara UM, Karthik KS, Udita The C.V. Mosby Co.; 1964. Pp. 115, 453-60.
SM. A review on Diagnosis and treatment planning for 26. Sudhakara V M, Karthik KS. A review on posterior
completely edentulous patients. JIADS 2010; 1(1): 16- palatal seal. JIADS 2010; 1(1):16-21.
21. 27. Ansari HI. Estabishing the posterior palatal seal during
8. Colon AK, Kotwal K, Mangelsodroff AD. Analysis of the final impression stage. J Prosthe Dent 1997; 78(3):
the posterior palatal seal and the palatal form as 324-6.
related to the retention of complete dentures. J 28. Vinton PW. Posterior palatal seal. personal
Prosthet Dent 1980; 47(1): 23-7. communication, 1971.
9. Swenson MG, Terkla LG. Complete denture. 6th ed. St
Louis: The C.V. Mosby company; 1970. pp. 65-70,
372-6.
Table 1: Means and standard deviation of Group A

Group A Mean N Std. Deviation
A1 309.3333 3 17.92577
A2 186.0000 3 12.16553
A3 119.6667 3 13.61372
Total 205.0000 9 84.33119
Table 2: ANOVA and LSD of group A

Group A Sum of squares df Mean square F Sig.
Between Groups 55584.667 2 27792.333 127.358 0.000
Within groups 1309.333 6 218.222
Total 56894.000 8
Group A Mean Difference (I-J) Std. Error Sig.

A1 A2 123.33333 12.06157 0.000
A3 189.66667 12.06157 0.000
A2 A3 66.33333 12.06157 0.002
The mean differences is significant at the 0.05 level
Table 3: Means and SD of group B (deep palatal vault)

Group B Mean N Std. Deviation
B1 490.0000 3 10.00000
B2 480.0000 3 20.00000
B3 257.0000 3 23.30236
Total 409.0000 9 115.21936
Table 4: ANOVA and LSD of group B

Group B Sum of squares df Mean square F Sig.
Between Groups 104118.000 2 52059.000 149.738 0.000
Within groups 2086.000 6 347.667
Total 106204.000 8
Group B Mean Difference (I-J) Std. Error Sig.

B1 B2 10.00000 15.22425 0.536
B3 233.00000 15.22425 0.000
B2 B3 223.00000 15.22425 0.000
Table 5: Means and standard deviation of Group C

Group C Mean N Std. Deviation
C1 399.3333 3 6.02771
C2 392.6667 3 11.23981
C3 244.3333 3 41.78915
Total 345.4444 9 78.97011
Table 6: ANOVA and LSD of Group C

Group C Sum of squares df Mean square F Sig.
Between Groups 46072.222 2 23036.111 36.201 0.000
Within groups 3818.000 6 636.333
Total 49890.222 8
Group C Mean Difference (I-J) Std. Error Sig.

C1 C2 6.66667 20.59666 0.757
C3 155.00000 20.59666 0.000
C2 C3 148.33333 20.59666 0.000
Figure 1: Strain gauge force tranducer Figure 2: Physiological impression of pps
Figure 3: All casts of each groups Figure 4: Astring of 1 inch in length on the
polished surface
Figure 5: The patient during testing procedure
J Bagh College Dentistry Vol. 24(2), 2012 An evaluation of the
An evaluation of the use different techniques of the

thermoplasticized obturators on the coronal seal
Mervat M. Al-Bakri, B.D.S., M.Sc. (1)
Hussain F. Al-Huwaizi, B.D.S., M.Sc., Ph.D. (2)
ABSTRACT
Background: The aim of the present study was to evaluate coronal leakage of root canals obturated by various
techniques.
Methodology: Straight single rooted teeth with mature apices (6 groups of 10 teeth each). Root canals were
prepared according to the crown down technique using hand ProTaper system. Endofill root canal sealer and 2.5%
sodium hypochlorite was used. Root canals were obturated using cold lateral condensation Thermafil and Soft Core
obturation after root canal filling the six groups was divided into two individual groups of 30 teeth. The first group of 30
teeth was kept for 1 week the second 3 week at 37 oC. Teeth were immersed in india ink. Each was split and
sectioned longitudinally and the maximum extent of leakage was measured using a stereomicroscope
Results: Leakage occurred whatever filling technique was used the number of teeth with gross leakage decreased
with time up to 3 weeks. There were significant differences in coronal leakage between the various obturation
techniques after 1 week, and after 3 weeks. No statistically significant differences were found between soft-Core and
cold lateral condensation after 1 week and statistically significant differences were found after 3 weeks. There were
statistically significant differences between Thermafil and lateral condensation after 1 week and no statistically
significant differences after 3 weeks.
Conclusion: Under the conditions of the present study none of the gutta-percha obturation techniques prevented
coronal leakage. Coronal leakage increased during the first week for CLC, Thermafil and Soft-Core obturators, and
decreased after 3 weeks. Coronal leakage in the Soft-Core obturators was higher than Thermafil and CLC after one
week. Thermafil coronal leakage was lower than others after one week. Coronal leakage in the Soft-Core obturators
higher than Thermafil and CLC after three weeks coronal leakage was equal in Thermafil and CLC after three weeks.
Keywords: Endofill root canal sealer HPT, leakage, obturtion, CLC, Thermafil, Soft-Core. (J Bagh Coll Dentistry
2012;24(2):18-20).
INTRODUCTION
The provision of a well-compacted and highly MATERIAL AND METHOD
tightly adapted root filling is one of the goals of Sixty extracted human straight single-rooted teeth
root canal treatment. However, contemporary with mature apices were used in this study. Both
obturation techniques and filling materials do not carious (limited occlusal and/or interproximal
seal completely the root canal system up to the lesions without pulp exposure) and non-carious
level of the cemento-enamel junction. Moreover, teeth were included. All teeth were stored in 10%
it is accepted that both apical and coronal leakage formalin until the sample was completed.
can occur following apparently successful root Sample preparation
canal treatment (1, 2). Several factors appear to The crowns were removed 2mm above the
influence the extent of both apical and coronal cement-enamel junction with a high-speed fissure
leakage. Furthermore, various root canal filling bur and water spray.
techniques based on heated or preheated gutta- After gross removal of pulp tissue, a size 10
percha have been introduced in order to enhance Flexofile was introduced into the canal until it
complete filling of the root canal. These include could be seen in the major apical foramen. The
warm vertical condensation (3), warm lateral working length was determined by subtracting 1
condensation (4), thermatic compaction (5), hybrid mm from this length. The root canals were
condensation, i.e. a combination of cold lateral prepared by means of a crown-down technique,
condensation and thermomechanical compaction using the Protaper Hand system until F3.
(6)
, thermoplasticized gutta-percha as a coating on The canals were copiously irrigated with 2.5%
a flexible carrier (7), and injection moulded sodium hypochlorite solution with a 27 gauge
thermoplasticized guttapercha (8). endodontic needle.
The aim of the present study was to evaluate The canals were dried with paper points and the
coronal leakage of root canals obturated by patency of the apical foramen was confirmed with
various techniques. a size 10 Flexofile. The roots were randomly
(1) Assistant lecturer. Department of Conservative Dentistry.
College of Dentistry, University of Baghdad.
divided into 6 experimental groups of 10 roots
(2) Professor. Department of Conservative Dentistry. College of each.
Dentistry, University of Baghdad
Following drying with paper points, the canals other 3 groups for 3 weeks. After which they were
were obturated by one of the following thoroughly washed with running water. The nail
techniques. varnish was removed, the teeth were then air
Group 1: Cold lateral condensation of gutta- dried. Longitudinal shallow grooves were made
percha on the buccal and lingual surface with a rotating
A standard size g.p cone that matched the master diamond disc of small diameter under continous
apical file was fitted to the working length with water cooling, and the teeth carefulyl fractured
atugback Endofill root canal sealer was mixed and sectioned with a sharp chisel.
according to the manufacturer's instructions and The degree of microleckage was determined by
placed in the canal by coating the cone with sealer measuring the linear extent of India ink
and gently seating it at the working length. Lateral penetration from the surface of the coronal g.p at
condensation was then carried out using size 20 the level of the amelocemental junction to the
and 25 accessory g.p cones with endotontic finger position of the maximum dye penetration apically
spreader placed within 1 mm of the working (coronal leakage testing).
length. The g.p cones coated with sealer were To eliminate bias, coronal leakage were measured
laterally condensed until they could not be independently by two evaluators who were
introduced more than 3mm into the root canal. unaware of the obturation techniques used. All
Following obturation, the g.p was removed from measurements were obtained by means of a stereo
the coronal cavity up to the level of CEJ with a microcope with calibrated scale ocular.
warm instrument and vertically condensed with
Machtou pluggers.
Group 2: Thermafil obturation RESULTS
The correct size of the plastic core thermafil The teeth showed dye penetration along the entire
obturator was selected using the verification kit. length of each root canal. No significant
The obturators were then placed in the Therma- differences amongst the observers were scored, so
prep oven according to the manufacturer's that the calculation of the average leakage values
instructions. The sealer was sparingly introduced of the two observers for each root was justified.
into the canal, after which the plasticized Since the data indicated a non-normal
thermafil device was inserted to the apical stop. distribution, leakage was assigned using the
The shank of each carier was cut at the canal following categories:
orifice using an inverted cone bur in a high speed Coronal leakage was measured to the deepest
hand piece and the g.p was compacted vertically point.
with a plugger. Statistical analysis was carried out using the
Group 3 Soft core obturation ANOVA test between six groups to determine
The correct size of the plastic core Soft-Core whether there were significant differences
obturator was selected using the size verifier. The between the groups. Pairs of groups were
obturators were then placed in the Soft Core Over compared using the LSD or t-test.
(Soft Core System). When the oven indicated that Linear coronal leakage of the experimental
the obturator was ready, it was removed from one roots
of the slots in the top of the oven endofill sealer The result for coronal leakage is provided in table
was sparingly introduced into the canal, after 1. There were significant differences in coronal
which the plasticized Soft Coe device was leakage between the various obturation techniques
inserted into the apical stop. The handle and after 1 week, and after 3 weeks. According to the
insertion pin were removal by a twisting motion. t-test statistically significant differences were
Excess plastic core material was removed with a found between Soft-Core obturators and
small inverted cone bur and any extra g.p Thermafil after 1 week and after 3 weeks.
removed. The g.p was then compacted vertically No statistically significant differences were found
with a Machtou plugger. between soft-Core and CLC after 1 week and
Staining, longitudinal splitting and dye statistically significant differences were found
measurement after 3 weeks. There were statistically significant
After obturation, the teeth were stored in 100% differences between Thermafil and lateral
humidity for 48 hr. to ensure the sealer was set. condensation after 1 week and no statistically
The roots were covered with a nail varnish, the significant differences after 3 weeks.
first coat was allowed to dry and a second coat
was applied. All teeth were immersed in a bath of
India ink and stored at 37oC for 1 week and the
Table 1. Descriptive statistics of the groups differences in methods of measurement of coronal

leakage also the result of this study was in
agreement with Saunders and Saunders (12) in
which after 7 days, there was significantly less
leakage in these teeth obturated with Thermafil.
REFERENCES
1. Hovland EJ, Dumsha TC. Leakage evaluation in vitro
of the root canal sealer cement sealapex. International
Endodontic Journal 1985; 18: 179-82.
2. Saunders WP, Saunders EM. Coronal leakage as a
cause of failure in root canal therapy: a review.
Endodontics and Dental Traumatology 1994; 10: 15-8.
3. Schilder H. Filling root canals in three dimensions.
Dental Clinics of North America 1967; 11: 73-44.
4. Endotec Thermal Endodontic Condenser System. The
warm lateral condensation Technique Clinical Manual.
Dentsply Int. Inc. Milford DE. USA: The LD Caulk
Division. 1986.
Figure 1: The coronal leakage of the 5. Mc Spadden JT. Self study Course of the Thermatic
Condensation of Gu Ha Bercha. Dentsply Int. Inc.
different groups in different times Milford DE. USA: LD Caulk Division. 1980.
6. Tagger M, Tamse D, Katz A, Korzen BH. Evaluation
of the apical seal produced by a hybrial root canal
DISCUSSION filling method, combining lateral condensation and
In order to evaluate the sealing ability of root thermatic compaction. Journal of Endodontics 1984;
fillings, several in vitro methods have been 10: 299-303.
designed. It is important to appreciate that not 7. Johnson WB. A new gutta-percha technique. Journal
only is the apical seal of the root canal of of Endodontics 1978; 4: 184-8.
8. Yec FS, Marlin J, Krakow AA, Gron P. Three-
importance, but the coronal seal is of equal
dimensional obturation of the root canal injection
importance for the success of treatment (9). The molded, thermoplasticized dental gutta-percha. Journal
most common method used to assess leakage of Endodontics 1977; 3: 168-74.
remains the measurement of dye penetration (9). 9. Wu MK, Wesselink PR. Endodontic leakage studies
The result of dye penetration studies, however, is reconsidered Part I: Methodology, application and
confusing and often results in variable relevance, International Endodontic Journal 1993; 26:
37-43.
conclusions (10). This lack of agreement has been
10. Dalat DM, Spangberg LSW. Comparison of apical
discussed by Wu and Wesselink (9), who leakage in root canals obturated with various gutta-
questioned, the validity of leakage studies and percha techniques using a dye vacuum tracing method.
recommended that more research should be Journal of Endodontics 1994; 20: 315-9.
devoted to leakage study methodology. 11. Kontakiotis E, Chaniotis A, Georgopoulou M. Fluid
Longitudinal sectioning of roots and the linear filtration evaluation of 3 obturation techniques 2007.
12. Saunders WP, Saunders E. Influence of smear layer on
measurement of dye penetration were used in the
the coronal leakage of thermafil; laterally condensed
present study for the measurement of leakage. guttapercha root fillings with a glass ion sealer, 2012.
Splitting the root longitudinally combined with
dye penetration enable the demonstration of the
pattern of dye penetration.
In the present study obturation with soft core
obturators resulted in greater leakage scores.
This may indicate that Soft Core obturators are in
effective these might be related to Soft Core has
less taper core so more gutta percha-core ratio
than Thermafil therefore it exerts more
contraction. In addition, it was also seen that
coronal leakage decreased with time up to 3
weeks in all three obturation techniques.
In this study we found that Thermafil coronal
leakage was lower than other obturation
techniques and this result was disagree with
Kontakiotis et al (11). These might be related to the
J Bagh College Dentistry Vol. 24(2), 2012 An evaluation of apical
An evaluation of apical microleakage in roots filled with

thermoplastic synthetic polymer based root canal filling
material (RealSeal 1 bonded obturation)
Nadine J. Adbul-rada, B.D.S. (1)
Adel F. Ibraheem, B.D.S., M.Sc. (2)
ABSTRACT
Background: This study aimed to evaluate and compare the apical microleakage of roots canal filled with cold
lateral condensation of gutta-percha, cold lateral condensation of Resilon, Thermafil and RealSeal1 bonded
obturation.
Materials and methods: Sixty freshly extracted maxillary first molars with straight palatal roots .Using diamond disc bur
with straight hand piece and water coolant the palatal roots of teeth were sectioned perpendicular to the long axis
at the furcation area. All roots were prepared with crown-down technique using hand ProTaper system (Sx-F4).The
prepared roots randomly divided into 4 groups of fifteen roots each; the groups obturated with different obturation
technique. In Group 1 roots obturated with( lateral condensation of gutta-percha), Group 2 was obturated
with(lateral condensation of Resilon),group3 was obturated with (Thermafil) while in group4 obturated with( RealSeal
1 bonded obturation).All the samples sealed coronally and stored in normal saline at 37°C for one week ,then all the
roots submerged Indian ink for one week. The roots were cleared and the degree of linear dye penetration was
measured in millimeter by stereomicroscope under 40X magnification with calibrated scale ocular grid.
Results: The results showed that the RealSeal1 bonded obturation leaked apically significantly higher than other test
groups, while the group of lateral condensation of gutta-percha exhibited the least value of apical microleakage.
Conclusion: The complete hermetic apical seal cannot be created neither with gutta-percha nor with Real Seal
1bonded obturation.
Keywords: Apical microleakage, gutta-percha, RealSeal 1bonded obturation. (J Bagh Coll Dentistry 2012;24(2):21-
26).
INTRODUCTION
Complete obturation of the root canal with an In 2004, a new core material Resilon
inert filling material and creation of a fluid-tight (Resilon Research LLC, Madison, CT, USA)
seal are among the major goals of successful in conjunction with an adhesive system
endodontic treatment (1).The main three functions (Epiphany, Pentron Clinical Technologies,
of obturation are to entomb any bacteria Wallingford, CT, USA) was introduced to
remaining within the root canal system; to stop the market. Thisthermoplastic-filled polymer
the influx of periapical tissue derived fluid from core polycaprolactone-based has potential to
entering the root canal to feed the surviving challenge gutta-percha the ‘gold standard as
bacteria; and to prevent coronal leakage of a root filling core material (5). Resilon is a
bacteria. Although gutta-percha has many thermoplastic synthetic polymer- based root
desirable properties, including chemical stability, canal filling material. Based on polymer of
biocompatibility, non porosity, radiopacity and polyester, Resilon contains bioactive glass
the ability to be manipulated and removed, it does and radiopaque fillers. Epiphany is a dual
not always meet the three functions of curable resin composite used as a sealer
obturation(2). combined with Resilon points. According to
Gutta-percha does not bond to the internal manufacturer, Epiphany sealer bonds both to
tooth structure, resulting in the absence of a dentin and also to root canal filling material.
complete seal (3).Many attempts have been made This may be an important fact to eliminate
to resolve the problem through the variation in microleakage since it is well-known that
obturation technique including vertical and lateral microleakage occurs not only through sealer-
condensation and the use of reverse-fill or touch dentin but also through sealer and root canal
and heat system. filling material Interfaces (6,7).
These methods have reduced microleakage to
ascertain degree but still have failed to eliminate MATERIALS AND METHODS
( ).
the problems 4 Samples Selection
Sixty freshly extracted maxillary first molars
(1)M.Sc. student, dep. of conservative dentistry, college of teeth. The criteria for teeth selection Straight root
dentistry, university of Baghdad. canal mature centrally located apical foramen,
(2)Professor dep. of conservative dentistry, college of dentistry,
university of Baghdad. patent apical foramen, roots devoid of any
resorption, cracks or fracture and the palatal roots by the spreader; this was followed by more
will be 10mm in length from the apex up to spreading and more accessory cone until the
furcation area(8). spreader could not enter more than 2-3 mm into
Samples preparation the canal orifice. When obturation of teeth was
After extraction, all teeth will be stored in distilled accomplished, the excess gutta-percha removed
water at room temperature. Any soft tissue with heated endodontic plugger to a level (1mm)
remnants on the root surface were removed with higher than the coronal end of roots and vertically
sharp periodontal curette. The crown of the tooth condensed with root canal plugger, so the gutta-
was sectioned perpendicular to the long axis of percha obturate the entire canal up to the coronal
the root at the furcation area with a disc diamond terminus. The roots were coronally sealed by
and the root length adjusted to 10mm from flat temporary filling.
reference point to the root apex. The patency of Group 2: In this group roots were obturated with
the canal was checked by passing# 10 K file 1mm Resilon and Real Seal SE sealer by lateral
through the apical foramen and the working condensation technique. The dual syringe (with
length equal to 9 mm. Silicon rubber base (heavy mixing tip) was used to express the sealer onto the
body) was mixed (Base and catalyst) according to mixing pad then the sealer was carried to the canal
the manufacturer instructions loaded with hand on the paper point according to manufacturer
and inserted it in a perforated plastic container instruction .The master cone size 40 was coated
(dimension 13mm, height 52mm) using spatula to with the sealer and placed into its correct working
adapt heavy body to the wall of the plastic length within the canal. A finger spreader size 35
container then the sectioned root centered inside was inserted between the master cone and the
the rubber base. Heavy body left to set forming canal wall within 1-2 mm from the working
small blocks to facilitate handling of roots during length. Spreader taper is the mechanical force that
instrumentation and obturation. The canals were laterally compresses and spreads Resilon creating
prepared with crown-down technique using (hand a space for additional accessory cones. The tip of
use) Protaper system (Sx to F4). According to the accessory point size #20 was dipped in the sealer
manual instruction, the motion of instrumentation and inserted into the canal by space left by the
was clockwise reaming action with sufficient spreader; this was followed by more spreading
apical pressure till the file engaged the dentin and more accessory cone until the spreader could
about four rotations at each time till the file not enter more than 2-3 mm into the canal orifice.
became passive, then the file was pulled and its The excess Resilon was seared off with a hot
flutes cleaned from the dentin debris frequently endodontic plugger and vertically was condensed
and inspected for any sign of distortion. with endodontic plugger and then the coronal
Obturation of the roots: third of each root was cured using the light curing
Group 1: In this group roots were obturated with device for 40 seconds according to manufacturer
cold gutta-percha points (lateral condensation instruction. The coronal 1 mm of each root sealed
technique) using AH-26 sealer. AH-26 was mixed with glass ionomer cement as a temporary
a, on a dry, clean glass slab with spatula. The restoration according to manufacturer of Real Seal
mixture had a homogenous creamy consistency system.
that string out at least one inch when the spatula Group3: In this group roots were obturated by
was raised slowly from the glass slab. The canal Thermafil cones and AH-26. The stoppers were
was dried using paper point and sealer was placed on the cone according to the working
introduced into the canal to full working length length and then the matching size verifier was
using file F4 by pumping action of the file with inserted into the canal to the working length. The
simultaneous rotary movement in a counterclock sealer was introduced into the canal in the same
direction to coat the canals with thin film of manner as Group 1. Thermafil cones (size 40)
sealer. The tip of master gutta-percha cone were placed in one of the heating chamber of
corresponding to the last file size #40 was dipped ThermaPrep plus oven (Size 30-60 button is
into the sealer and placed in the canal. The chosen). After beep sound, the oven was switched
previously checked finger spreader size 35 is off then the cone raised without rotation and
inserted between the master cone and the canal inserted inside the canal firmly and slowly to
wall within 1-2 mm from the working length. working length without any twisting or rotation.
Spreader taper is the mechanical force that The handle was removed after the gutta-percha
laterally compresses and spreads gutta-percha cooled by inverted cone bur in high speed hand
creating a space for additional accessory cones. piece. The roots were coronally sealed by
The tip of accessory point size #20 was dipped in temporary filling (Citodur).
the sealer and inserted into the canal by space left
Group4: In this group roots were obturated with under 40X magnification with calibrated scale
Real Seal 1 obturator and Real Seal SE sealer ocular to establish the degree of apical dye
according to manufacturer instruction. The penetration in millimeters.
stopper was placed on the matching size verifier
and then it inserted into the canal to the working
length. The verifier should fit passively in the
canal. Then RealSeal 1 (size 40) were placed in
one of the heating chamber of RealSeal 1 oven
(Size 40-60 button is chosen). The heating time
needed to heat RealSeal1was regulated
automatically about1:30 minutes, during this time
SE sealer was dispensed and introduced to the
canal in the same manner as Group 2. After the
first” beep” signal the obturator is ready for
Figure 1: The cleared sample of Real Seal 1
removal from the unit and inserted in the canal
within 6 seconds without any twisting or forcing.
bonded obturation.
The handle and the shaft were removed with RESULTS
inverted cone in a high speed hand piece then was Table 1: Descriptive statistic of analysis for
light cured the coronal surface of the RealSeal1 experimental groups
obturator for 40seconds. The coronal 1 mm of Group N Mean S.D SE Min max
each root sealed with glass ionomer according to 1 13 0.4385 0.08697 0.02412 0.30 0.60
the manufacturer instruction. 2 13 0.8692 0.16013 0.04441 0.40 1.00
Sample storage: After obturation the samples 3 13 0.5115 0.13095 0.03632 0.30 0.75
were stored in incubator at 37°C for a week to 4 13 0.9154 0.08987 0.02493 0.80 1.00
ensure complete setting of the sealer (9).
Leakage study: Each group had one root as a Table 1 shows that, group 1 (lateral condensation
negative control and one root as a positive control. of Gutta-percha) have the lowest mean value of
The negative control roots were coated dye penetration (0.4385) while the highest mean
completely with one layer of nail varnish and two value of dye penetration was for group 4 (Real
layers of sticky wax, while positive control roots Seal 1) (0.9154). The rest values of other groups
were left uncoated .While each experimental root were fluctuation between these values. To identify
was coated with one layer of nail varnish and two the presence of statistically significant difference
layers of sticky wax except for the apical 2mm. for apical dye penetration between groups,
Indian ink was used as leakage indicator for all ANOVA test and t- test was carried on. The
groups (10).A puncher was used to make hole in results of t-test showed that there is a high
the center of the rubber cap to create space into significant difference between all the groups
which the coronal third of each root passed and except for 1&3 and for2&4 the difference was
fixed to rubber cap. The apical 3 to 4 mm of each non-significant.
root was immersed in a glass vial containing
Indian ink and deposited in an incubator at 37ºC DISCUSSION
for a week. At the end of this period, the roots Three dimensional sealing of all portals of exist
were removed from the ink and washed under present in the root canal system have been the
running water in a position opposite to the apical ultimate goal of different obturation materials and
foramen for one minute. The sticky wax was techniques for many decades. Perfect adhesion
scraped from the root surface with a lacron carver qualities achieved by newer bonding systems
and washed again under running water (10). tempted clinicians to adopt such technology in an
Clearing process: The roots were decalcified (the attempt to provide better seal for the root canal
tooth can be pricked by sewing pin) with 5% system. A new resin obturating materials
nitric acid for a period of 5 days, renewing the “RealSeal1” was tested in the present study for its
acid daily. The roots were then washed under ability to provide three dimensional sealing for
running tap water for 30 minutes and dehydrated root canals. In this study the maxillary first molar
by 99-100% ethyl alcohol for 3 days with daily have been used ,the palatal roots were sectioned at
change of alcohol, and then all the roots became the furcation area to eliminate the variables in
transparent by immersion in methyl salicylate for access preparation design, since if the crown
24hours (11).Linear dye penetration was measured present each tooth would1 and to get flat
from the apical foramen to the maximum reference point for measurements(12).Root canals
extension of the dye using light stereomicroscope were prepared using ProTaper hand system
because it provide minimum degree of apical al.,(27),they found that the new RealSeal1 material
microleakage when compare with Rotary (carrier-based Resilon) showing significantly
ProTaper(13).EDTA was used as irrigant in order to better sealing ability than the traditional carrier-
remove the smear layer because many studies based gutta-percha systems, this may be explained
advocate its removal to reduce microleakage(14) by different evaluation method because they used
also deionized water is used as a final irrigant fluid filtration method and also disagree with
according to manufacturer instruction. AH-26 study conducted by Duggan et al.,(28) that found
sealer was selected and used in this study because that RealSeal1 appeared to resist bacterial
have the lowest leakage value compared with penetration more effectively than Thermafil this
other types of endodontic sealer (15).SE Real Seal disagreement may be attributed to their study
sealer have been used with a synthetic polymer- which is carried on a dog model after inoculation
based core material (Real Seal 1, Resilon) a coronally for 4 months.
according to the manufacturer instruction. 4.2 3. Resilon, Gutta-Percha and Thermafil
Leakage studies constitute a major part of The Resilon showed higher leakage value and a
contemporary endodontic research. .The most highly significant difference was found with
common method used remains the measuring of gutta-percha and Thermafil groups, this may be
liner penetration of dye, but the nature and related to the same reasons that are mentioned in
amount of leakage observed with this technique paragraph 4.2, in addition to that inadvertent
cannot be extrapolated to an in vivo situation. stripping of sealer off the canal wall during
Measurements of dye penetration were made after placement of cones (29, 30) and disruption of the
decalcifying and clearing the root which it renders maturing resin root dentin bond during lateral
the root transparent, enables three dimensional condensation or other technique(29, 30).The results
observation of the dye penetration, which can be of present study were in agreement
recorded to its maximum extent and also evaluate with(31,32,33)and disagreed with Lumnije et al.(34)
whether or not associated with porosities, the they found that Resilon had less dye penetration
presence of empty spaces and stripping of gutta- in comparison with gutta-percha and this may be
percha from solid core system(16).This explains related to different type of sealer used and
using clearing method for measuring different method of evaluation because they used
microleakage for this study. This method dye extraction determined with
commonly used because it is easily accomplishes spectrophotometer. Wedding et al.(35) found that
and does not require sophisticated materials (17-19). Resilon exhibited a statistically significant
1. Real Seal 1 and Resilon: In this in vitro study, increased resistance to fluid movement compared
the highest mean of leakage value was observed with gutta-percha and AH-26 sealer. This may be
in RealSeal1 and Resilon with no significant due to different method of preparation and
differences, this might be related to same different evaluation methods because they used
composition of materials and both contain fluid filtration microleakage test.
methacrylate monomer. 4. Gutta-percha and Thermafil :In this in vitro
2. Real Seal 1, Gutta-Percha and Thermafil: study, lateral condensation of gutta-percha group
The Real Seal 1 showed the most leakage value show the least leakage with non-significant
with highly significant difference was found with difference with Thermafil group which they
gutta-percha and Thermafil groups. This might be provides best apical sealing .This finding was in
related to that the methacrylate-based materials agreement with(36-38,10,39)while these results
undergo volumetric shrinkage during the disagreed with Inan et al.(40)found that Thermafil
polymerization process(20-22) also the root canal have the lowest mean leakage values than the
have high cavity configuration factor that highest were observed for lateral condensation of
contribute to polymerization stresses created by gutta-percha., this may be attributed to difference
resin-based materials along root canal walls(23). evaluation methods because they used
Tay et al.(24)found that polymerization of the electrochemical evaluation .
sealer may be promoted by heat generated during
softening of the material. Another plausible
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J Bagh College Dentistry Vol. 24(2), 2012 The effect of two types
The effect of two types of disinfectant on shear bond

strength, hardness, roughness of two types of soft liners
Rola W. Abdul-Razaq B.D.S., M.Sc. (1)
ABSTRACT
Background: Poor oral hygiene results in accumulation of dental plaque and dental biofilms, especially in elderly
with denture, regular cleaning of the dentures using chemical or physical methods can minimize the risk of
(stomatitis) in denture users. The aim of this study was to evaluate the effect of two types of disinfectant on some
mechanical properties of two types of soft liners.
Materials and methods: 180 specimens from 2 types of soft liners (Mollosile, Viscogel) were prepared and divided into
2 major groups, mollosile group, viscogel group for each test and each major group is divided into 3 subgroups, each
subgroup includes 10 specimens. Hardness and roughness test specimens were consist of two discs, acrylic disc with
dimensions(4mm,15mm)thickness, diameter respectively and soft liner disc with dimensions (2mm,15mm) thickness,
diameter respectively. For shear bond test, specimens were prepared from two blocks of acrylic measuring (75mm,
25mm, 5mm)length, width, depth respectively with stopper (3mm) and handle of (13mm) thickness and soft liner
material in the space between the two acrylic blocks. All specimens were stored in distilled water for 24 hours at 37Co
then they were immersed into water(control group) , Solo, Chlorhexidine 0.2 % disinfectant (test groups) for 8 hours to
simulate the weekly exposure time of soft liner with disinfectant. A profilometer device was used to measure the
roughness property and Shore A for hardness property and Micro-computer controlled electronic universal testing
machine for shear bond property.
Results: The results revealed that there was a significant difference in roughness mean values for each soft liner after
immersed in disinfectant solutions while there was no significant difference in mean values of (hardness, shear bond
strength) for each soft liner after immersed into disinfectant solutions.
Conclusion: Disinfectant solutions (SOLO, CHLORHEXIDINE) had no effect on hardness and shear bond strength of soft
liners (MOLLOSILE, VISCOGEL) while they had effect on surface roughness by decreasing the surface roughness of
these soft liners which is a favorable condition.
Keywords: Soft liner, Disinfectant, Roughness, Hardness, Shear bond. (J Bagh Coll Dentistry 2012;24(2):27-31).
INTRODUCTION
The clinical use of soft denture lining materials materials are considered to be useless (6).
was first reported in 1943(1).Soft lining materials Prosthesis have been identified as a source of
are able to form an absorbing layer on the part of cross contamination between patient and dental
the denture in contact with oral mucosa and this personal, so chemical disinfectant are a
allow less traumatic transmission of occlusal recommended method to prevent cross
forces(2). The use of soft liners has become contamination when used after removal and
increasingly popular for providing comfort for before insertion of prosthesis into mouth (7). A
denture wearers. Soft liners are often used for denture disinfectant method should be effective
patients who cannot tolerate a conventional for inactivation of microorganisms without
denture base (3). These materials have several adverse effects on the denture materials (8). The
disadvantages including color stability, resiliency, aim of this study was to investigate the effect of
abrasion resistance, bond strength and porosity (4). chemical disinfectant (solo, chlorhexidine 0.2%)
The ideal hardness or softness for providing a on shear bond strength, hardness, surface
greater comfort to the patient can be obtained with roughness of two types of soft liners (mollosile,
the use of soft materials, so hardness is important viscogel) .
property for resilient material and should remain
constant for a long period so that the material can MATERIALS AND METHODS
efficiently fulfill their functions. Surface Totally 180 specimens were prepared from 2
roughness is also important property; a rough types of soft liner (mollosile, viscogel) both of
surface can lead to biofilm accumulation and them are room temperature curing soft liner and
colonization of Candida albicans, which is the 240 specimens of heat cure acrylic (Major dent,
major etiological factor for denture-induced Italy) were prepared for surface roughness,
stomatitis .The denture made from two different hardness, shear bond tests. They were divided into
materials can only be successful if there is an 2 major groups (molosile , viscogel) group for
adequate bond between the materials (5), so the each test, each major group includes 30
favorable properties of a denture liner in the specimens and divided into 3 subgroups, each
absences of good adhesion to denture base subgroup includes 10 specimens: Mw: mollosile
(1) Assistant lecturer, dep. of prosthetic dentistry, college of
dentistry, Baghdad University.
specimens in water. Ms:mollosile specimens in
solo.Mc: mollosile specimens in chlorhexidine.
The same specimen groups for viscogel material.

Surface roughness and Hardness test: The solutions (solo, chlorhexidine 0.2 %) for 8 hours
specimens of these tests consist of a disc of to simulate the weekly exposure of soft liner with
(15mm) in diameter and (4mm) in thickness of disinfectant(3). After that the specimens were
heat cure acrylic resin with (2mm) thick layer of tested for shear bond strength using Micro-
the soft liner bonded to each disc. A brass pattern computer controlled electronic universal testing
was constructed in a form of disc (15mm, 4mm) machine and subjected to shear load with cross
diameter, thickness respectively for preparation of head speed (2mm/min) using load cell capacity
acrylic disc and a silicone mould was prepared (10 Kn), shear bond was calculated according to
from which a wax patterns with dimensions of the following formula:
(15mm, 2mm) diameter, thickness respectively Bond strength = F(n)/A(mm)2 (ASTM,
were produced. The disc of wax was placed on the specification D-638m, 1986).
disc of acrylic and both of them were invested as
one piece inside the lower half of conventional
dental processing flask that was filled with dental RESULTS
stone mixed according to the manufacturer’s Mw: mollosile specimens in water
instructions (dental stone Elite model, Italy) to Ms: mollosile specimens in solo
prepare a mould for final specimens, a piece of Mc: mollosile specimens in chlorhexidine
glass was placed over the wax so the level of wax Vw: viscogel specimens in water
is with the level of stone and smooth surface of Vs: viscogel specimens in solo
soft liner is created, after setting of stone, wax Vc: viscogel specimens in chlorhexidine.
elimination was done and the mould was cleaned
and left to dry then the soft liner was mixed Roughness test:
according to the manufacturer’s instructions and Table1: Descriptive statistics for surface
applied into the mould by spatula, the flask was roughness test in (µm) for mollosile material.
closed and pressure was applied by using Group Sample No. Mean (µm) S.D.
hydraulic press up to 100 Kpa then the pressure Mw 10 1.25000 0.55025
was released and the flask was left for bench cure. Ms 10 0.58000 0.15491
After complete curing the specimens were Mc 10 1.22000 0.50508
removed and by using sharp knife the excess of
material was removed after that the specimens Table 1 shows the mean values and the S.D. of
were stored in distilled water for 24 hours at 37Co surface roughness for mollosile material, the
then they were immersed in disinfectant solutions highest mean value was for water group and the
(solo, chlorhexidine 0.2 %) for 8 hours to simulate lowest mean value was for solo group.
the weekly exposure of soft liner with
disinfectant(3). After that the specimens were Table 2: Analysis of variance (ANOVA) test
removed and tested. A profilometer device was for surface roughness for mollosile material
used to study the surface roughness property of Mean F-
Source d.f. P-Value Sig.
each soft liner, and Shore A hardness tester was square Value
used to measure the indentation hardness of each Between
2 1.432
soft liner. groups
7.38 0.0028 H.S
Shear bond strength test: The specimens of this Within
27 0.193
test consist of 2-heat cure acrylic blocks with groups
dimensions of (75mm, 25mm, 5mm) length, P>.05(non-significant),p<.05(significant),p<.01(highly
significant).
width, depth respectively with stopper of (3mm)
and handle of (13mm) in thickness. A metal
pattern was constructed with the same dimensions Table 3: L.S.D. test between control and test
mentioned above to prepare acrylic specimens, groups of mollosile material for surface
each soft liner was mixed according to the roughness test
manufacturer’s instructions and applied by spatula Difference between L.S.D.
Groups Sig.
into the space between the two acrylic blocks, any mean 0.05
excess of material was removed by using sharp mw*ms 0.67 H.S.
knife and the specimen was put under weight mw*mc 0.03 0.4041 N.S.
(200)g for stability and left for bench cure, after ms*mc 0.64 H.S.
complete curing the specimens were stored in
distilled water for 24 hours at 37Co, then the ANOVA test was described in table 2 which
specimens were immersed into disinfectant shows highly significant difference for mollosile
material groups. L.S.D test in table 3 shows a
highly significant difference for mw*ms and Table 8: Descriptive statistics for hardness
ms*mc while non significant difference for test for viscogel material
mw*mc. Group Sample No. Mean S.D.
vw 10 41.6000 7.08989
Table 4: Descriptive statistics for surface vs 10 41.7000 3.49761
roughness test in (µm) for viscogel material vc 10 41.8000 6.35609
Group Sample No. Mean (µm) S.D.
Vw 10 2.89000 0.45570 Table 9: Analysis of variance (ANOVA) test
Vs 10 2.63000 0.08232 for hardness for mollosile material
Vc 10 0.86000 0.47187 Mean F-
square Value
Table 4 shows the mean values and the S.D. of Between
2 0.6333
surface roughness for viscogel material, the groups
0.26 0.7739 N.S
highest mean value was for water group and the Within
27 2.4481
lowest mean value was for chlorhexidine group. groups
P>.05(non-significant),p<.05(significant),p<.01(highly
Table 5: Analysis of variance (ANOVA) test significant).
for surface roughness for viscogel material
Mean F- Table 10: Analysis of variance (ANOVA) test
Source d.f. P-Value Sig. for hardness for viscogel material
square Value
Between Mean F-
2 12.202 Source d.f. P-Value Sig.
groups square Value
83.8 <.0001 H.S Between
Within 2 0.1000
27 0.1457 groups
groups 0.00 0.9971 N.S
P>.05(non-significant),p<.05(significant),p<.01(highly Within
27 34.300
significant). groups
P>.05(non-significant),p<.05(significant),p<.01(highly
Table 6: L.S.D. test between control and test significant).
groups of viscogel material for surface

roughness test. ANOVA test was described in table 9,10 for
Difference L.S.D. mollosile and viscogel materials respectively
Groups Sig. shows non significant difference between control
between mean 0.05
vw*vs 0.26 N.S. group and test group for both materials.
vw*vc 2.03 0.3503 H.S.
vs*vc 1.77 H.S. Shear bond strength test:
Table 11: Descriptive statistics for shear
ANOVA test was described in table 5 which bond strength test in (N/mm2) for mollosile
shows highly significant difference for viscogel material
material groups. L.S.D. test in table 6 shows Mean
Group Sample No. S.D.
highly significant difference for vw*vc and vs*vc N/mm2
while non significant difference for vw*vs. mw 10 0.09300 0.00483
Hardness test: ms 10 0.09700 0.00483
Table 7, 8 shows the mean values and S.D. of mc 10 0.09600 0.00516
hardness test for mollosile and viscogel material
respectively, in general the results for control and Table 12: Descriptive statistics for shear
test group showed nearly the same mean values bond strength test in (N/mm2) for viscogel
for both materials. material
Mean
Group Sample No. S.D.
Table 7: Descriptive statistics for hardness N/mm2
test for mollosile material mw 10 0.06600 0.00516
Group Sample No. Mean S.D. ms 10 0.06500 0.00527
mw 10 26.3000 1.41813 mc 10 0.06400 0.00516
ms 10 26.6000 1.71216
mc 10 26.8000 1.54919 Table 11,12 shows the mean values and S.D. of
shear bond strength for both mollosile and
viscogel respectively, in general the results for
control and test groups showed nearly the same
mean values for both materials.
Table 13: Analysis of variance (ANOVA) test liners (Garcia et al,2003) stated that when these
for shear bond strength for mollosile materials were immersed in cleansing products a
material loss of soluble components occurred leaving
Mean F- empty spaces or bubbles which is responsible for
Source d.f. P-Value Sig. surface roughness, these bubbles or voids
square Value
Between underwent an increase in size that resulted in
2 .00004
groups crater, the limits of the craters are probably
1.77 0.1891 N.S
Within smaller when compared to the bubbles leaving
27 .00002
groups specimens smoother and these differences
P>.05(non-significant),p<.05(significant),p<.01(highly between the two materials are attributed to the
significant). different chemical structure of the 2 soft liners
(acrylic-base and silicone-base); therefore they
Table 14: Analysis of variance (ANOVA) test
have different properties and behaviors in the
for shear bond strength for viscogel material cleansers(14) , also changes of surface roughness of
Mean F- materials varied depending on both immersion
square Value
time and types of cleansers. Hardness is one of the
Between
2 .00001 most challenging factors in the use of complete
groups
0.37 0.6943 N.S denture liners, the greater the softness, the greater
Within
27 .00002 the extension in absorbing the impact effect, thus
groups
P>.05(non-significant),p<.05(significant),p<.01(highly less hardness is desirable characteristic for soft
significant). liners. In this study there is a non significant
difference in hardness property for both materials
when immersed in both types of disinfectant
ANOVA test was described in table 13,14 for solutions, this results can be attributed to type of
mollosile and viscogel materials respectively cleanser and type of soft liner because the type of
shows a non significant difference between denture cleansers are known to be important in
control group and test groups for both materials. assessment of the compatibility of cleansers with
soft liners (15) this result agrees with(Azevedo et
DISCUSSION al, 2006) who found that there is no significant
Although chemical denture cleanser have been changes in hardness regardless of disinfectant
considered to be efficacious method to prevent solutions used, so it appeared that in this respect
Candida albicans colonization and denture plaque the materials were likely to be equally effective
formation (9), daily use of denture cleanser can clinically.
affect the physical properties of denture acrylic Bond strength property of reline materials are
resin bases and soft liners(10),because when very important for their Cushioning effect which
immersed in soaking solutions or placed in oral allow for more even distribution and maintenance
cavity, soft liners undergo two processes, leaching of material shape, de-bonding results in
out of plasticizers and other soluble materials and unhygienic condition at the de-bonded region and
sorption of water or salivary components. So the causes functional failure of prosthesis(17) , both
fluctuation between these two processes affects materials shows a non significant difference in
the properties of denture liner material (11) . Aging shear bond strength when immersed in both
or changes in physical properties of soft denture disinfectant solutions, this can explain as,
lining materials appear to depend upon their type viscogel material is
or composition (12). polymethyl/ethylmethacrylate and acrylic is
Almost all soft liners became rougher to a greater polymethyle methacrylate , so according to
or lesser extent by the immersion into denture (Garcia et al,2003) chemical adhesion may be
cleansers. In this study mollosile material shows explained by similar chemical composition of
significant difference in surface roughness change acrylic resin and resilient liners , so the shear
which was decreasing in roughness when bond was not affected by the immersion in
immersed in solo while viscogel material shows disinfectant solutions. Mollosile material is
significant difference in surface roughness change silicone polymer based denture liner, the adhesion
which was decreasing in roughness when between mollosile and acrylic resin can be
immersed in chlorhexidine. This decrease in achieved by using an adhesive which is a solvent
roughness is favorable characteristic for soft liners that dissolve the PMMA surface, however there is
because surface roughness is very important no chemical adhesion but the shear bond by using
property of reline materials. This can be adhesive was not affected by the 2 types of
explained by, regarding the roughness of soft disinfectant solutions which is attributed to the
type of denture cleanser and type of soft liner and 13. Garcia RM, Leon BT, Oliveira VB, Del Bel Cury AA.
the compatibility between them as mentioned Effect of a denture cleanser on weight, surface
roughness and tensile bond strength of two resilient
before the type of denture cleanser is important in
denture liners. J Prosthet Dent 2003; 89: 489-94.
assessment of the compatibility of cleanser with 14. Abdul-Kareem AA. Effect of denture cleansers on
soft liner, also changes in physical properties of sorption, solubility, tensile bond strength and surface
soft liner depend upon their type and composition. roughness of two soft denture lining materials. A
master thesis, Prosthetic Department, University of
Baghdad 2006.
REFERENCES 15. Jin C, Nikawa H, Makihira S, Hamada T, Furukawa
1. Tylman S. The use of elastic and resilient synthetic M, Murata H. Changes in surface roughness and color
resins and their copolymer in oral, dental and facial stability of soft denture lining materials caused by
prosthesis. Dental Digest 1943; 49: 167. denture cleansers. J Oral Rehabil 2003; 30: 125-30.
2. Brozek R, Koczorowski R, Rogalewice R, Voelkel A, 16. Azevedo A, Machado AL, Vergani CE, Giampaolo
Czarnecka B, Nicholson JW. Effect of denture ET, Parvarina AC, Magnani R. Effect of disinfectants
cleansers on chemical and mechanical behavior of on hardness and roughness of reline acrylic resins. J
selected soft lining materials. Dent Mater J Prosthodont 2006; 15(4): 235-42.
2011;27(3):281-90.(IVL) 17. Kawano F, Dootz ER, Koran A, Craig RG.
3. Sarac D, Sarac YS, Kurt M, Yuzbasioglu E. The Comparison of bond strength of six soft denture liners
effectiveness of denture cleansers on soft liners to denture base resin. J Prosthet Dent 1992; 68: 368-
colored by food colorant solutions. J Prosthodont 71.
2007; 16(3): 185-91.
4. Anusavice KJ. Phillips’Science of dental materials 11th
ed. Philadelphia: Saunders; 2003. p. 269-71.
5. Segundo ALM, Pisani MX, Paranhos HFO, Souza RF,
Lovato CHS. Effect of a denture cleanser on hardness,
roughness and tensile bond strength of denture liners.
Braz J Oral Sci 2008; 7(26): 1596-601.
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duration on tensile bond strength of acrylic or silicone-
based soft denture liners to a processed denture base
polymer. Acta Odontal Scand 2005; 63: 31-5.
7. Hamouda IM, Ahmed SA. Effect of microwave
disinfectant on mechanical properties of denture base
acrylic resin. J Mechnical Behavior of Biomedical
Materials 2010; 05: 002.
8. Machado AL, Breeding LC, Vergani CE, Prerez
LEDC. Hardness and surface roughness of reline and
denture base acrylic resins after repeated disinfection
procedures. J Prosthet Dent 2009; 102(2): 115-22.
9. Nikawa H, Ntshlmura H, Yamamoto T, Hamada T,
Samaranayakl LP. The role of saliva and serum in
Candida albicans biofilm formation on denture acrylic
surface. Microbial Ecology in Health and Disease,
9:35.
10. Nikawa H, Iwanaga H, Hamada T, Yuiita S. Effect of
denture cleansers on direct soft denture lining
materials. J Prosthet Dent 1994(a); 72: 657.
11. Sinobad D, Murphy WM, Hugget R, Brooks S. Bond
strength and rupture properties of soft denture liners. J
Oral Rehabil 1992; 19: 151-60.
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Dynamic viscoelastic properties of processed soft
denture liners part I. J Prosthet Dent 1995(a); 73: 471.
J Bagh College Dentistry Vol. 24(2), 2012 Immunohistochemical detection
Immunohistochemical detection to evaluate the biological

role of Ti implants coated by a combination of fibronectin
protein and hydroxyapitate (EPD) (in vivo study)
Athraa Y.Al-Hijazi, B.D.S., M.Sc., Ph.D. (1)
Thair L-Al-Zubaydi, M.Sc., Ph.D. (2)
Eman I. Mahdi, B.D.S., M.Sc. (3)
ABSTRACT
Background: physicochemical and biochemical coating techniques that are investigated now a day to enhance
bone regeneration at the interface of titanium implant materials. The combination, however, of both organic and
inorganic constituents is expected to result into truly bone-resembling coatings and as such to a new generation of
surface-modified titanium implants with improved functionality and biological efficacy. This research was conducted
to study the expression of osteocalcin and growth hormone receptor as bone formation markers in coated and
uncoated implant in interval periods (3days,1,2and 6 weeks).,
Materials and methods: Commercially pure titanium (CpTi) implants coated with hydroxyapatite by EPD method and
with fibronectin protein, were placed in the tibia of (16) New Zeland white rabbits , immunohistochemical tests for
detection of expression of osteocalcin and growth hormone receptor were performed on all the implants of both
control and experimental groups (3days,1,2 and 6 weeks) healing intervals. Mechanical test (torque removal test)
was performed as an indicator for the presence of osseointegration and as a test for the mechanical property of
bone-implant interface to be primarily propping the interface machanics.
Results: The removal torque mean values in all studied groups uncoated and coated were increasing with
advancing time (higher at 6 than 2 weeks periods) and coated implant showed high value in comparsion to control.
Result shows that Immunohistochemical findings revealed high positive expression range from strong to moderate for
osteocalcin and growth hormone receptor in coated implant in comparison to uncoated. These results indicating
that a mixing of bioactive HA ceramic and FN increased the activity of coated layer which improved the bone
formation and maturation in bone-implant interface and enhance mechanical interlocking with bone.
Conclusions: The present study concludes that organic and inorganic surface modification for titanium implant
surface by HA and FN enhances bone formation and increase osseointegration.
Key words: fibronectin protein, dental implant biochemical bone markers osteocalcin, growth hormone receptor. (J
Bagh Coll Dentistry 2012;24(2):32-38).
INTRODUCTION Fibronectin is a large adhesive glycoprotein high-

The clinical success of dental implants is directed molecular weight extracellular matrix involved in
by implant surface and bone cell responses that many cellular processes, including tissue repair,
promote rapid osseointegration and long-term embryogenesis, blood-clotting,cell migration/
adhesion growth and wound healing. Coating of
stability Several surface modification have
dental implant with FN enhanced osteoblast
been proposed in order to promote differentiation and increases the rate of bone
osseointegration of titanium implants formation at the site of implantation
Hydroxyapatite (HA) is one of the most Osteocalcin is a bone specific non-collagenous
extensively used synthetic calcium phosphates for protein. Osteocalcin is synthesized by osteoblst
bone replacement and in dental field because of during bone formation and deposited mainly in
its chemical similarities to the inorganic
the extracellular matrix It is consider as
component of bone and teeth Hydroxyaptite
aspesific marker of osteoblast cells because
coated titanium implant have been becoming osteocalcin is involved in the process of osteoid
more popularly because long-term good clinical minerlization, the protein is expressed mainly
results and the quick new bone formation around
during phase of bone formation Growth
the implant of implantation occurs. These coating
have been found to accelerate intial stabilization hormone receptor (GHR) is a transmembrane
of implants by enhancing bony ingrowth and receptor for growth hormone. Binding of GH to
stimulating osseuos apposition to the promoting a GHR promotes receptor dimerization and initiates
a cascade of events leading to protein
rapid fixation of the devices to the skeleton
phosohorylation and activation of nuclear protein
(1) Professor, Oral Histology& Biology, College of Dentistry.
(2) Senior Scientific Researcher, Ministry of Science and transcription factors in osteoblasts GH has
Technology, Baghdad, Iraq. an effect on the proporations of hematopoietic and
(3) Assistant Professor, Oral Histology & Biology, College of
Dentistry. mesenchymal progenitor cells in the bone
Oral Diagnosis 32
marrow, and that GH is essential for both the accordance with the manufacture instruction
induction and later progression of osteogenesis (Abcam UK).
RESULTS
MATERIALS AND METHODS The result in this study show a significant higher
Materials torque was needed to remove implant
CpTi readymade implants from friatic electrophoreticall coated with HA and with
company were modified and machined in fibronectin protein (HEF) in (15.31N.cm, 30.28
diameter about 3.5mm, length of 8 mm (5mm was N.cm) 2 and 6 weeks of implantation respectively
threaded and 3mm was flat). Fibronectin protein than the uncoated implants. all values were
(Applied by Biosystem, CA, U.S.A). increasing with advancing time and significant
Hydroxyapatite powder (Merck, Germany). differences between different time periods was
-Ethanol 99.8% (GFs chemicals, Germany). present, P≤0.000(table1). Radiolgraphical
-Hydrogen peroxide black evaluation revealed cortical bone thickness with
-Protein black. clear radioopacity around the coated implant
-Biotinylated goat anti-mous IgG (Figure 1).
-Streptavidin peroxidase Immunohistochemical examination for
-DAB chormogen osteocalcin expression of implant in different
-Monoclonal antibodies were used in the present interval periods.
study (OC4-30, ab13418)(MAB 263,ab 11380) Titanium implant coated with fibronectin
respectively. protein and HA shows strong positive
-Abcam anti mouse HRP/DAB detection kit immunohistochemical localization of osteocalcin
(ab64259-15). and many progenitor cells are present nearby
Methods which shows positive reaction to osteocalcin at
Electrophoretic EPD coating was applied on the site of implant of 3 days duration (Figure 2,3).
dental implants suspension for HA was prepared In one week duration, moderate positive
by adding HA powder to the solvent which was immunohistochemical localization of osteocalcin
ethanol 100g/liber in a baker under continous protein in rabbit tibia in implant coated with HA
stirring .sixteen (16) Newzeland rabbits aged (10- and fibronectin protein is illustrated. Woven bone
12 months) were used in this study they were formation with positively stained osteoblast cell
divided into four groups for (3days 1,2 and 6 neucli, active fibroblast cells and in the
weeks) healing intervals (4) animals for each extracellular matrix of woven bone (Figure 4).
period. Animals were generally aneasthesised and At 2 weeks duration section of implant coated
atramatic surgical technique was performed to with HA and fibronectin protein shows numerous
prepare two holes in the tibia FN coated implant bone trabeculae within active woven bone, stain
was inserted in one hole and uncoated implant negatively as shown blue coloure with counter
(control) placed in the second one. haematoxyline stain while formative cells shows
In the left tibia HA coated implant was positive stain (Figure 5). The high power view
inserted in one hole and uncoated implant placed shows positive stain for the progenitor cell (Figure
in the second one. Animals we sacrificed after 6).
3ays 1,2 and 6 weeks. Threads of Ti implant coated with HA&FN for
Immunehistochemical examination(IHC) 6weeks duration shows positive DAB stain in
All tissue specimen samples and controls, osteoblast cell for osteocalcin (Figure 7).
were fixed in 10% neutral formation and Immunohistochemical examination for growth
processed in a routin paraffin blocks. Each hormone receptor expression of implant in
formalin-fixed-paraffin-embedded specimen had different interval periods.
serial section were prepared as follows: 5µm Primitive bone formation around fibronectin
thickness sections were mounted on clean glass coated implant of three days duration of
slides for routine haematoxylin and Eosin staining implantation and strong positive
(H&E), from each block of the studied sample and immunohistchemical stain for GHR is seen in
the control group for histopathological re- progenitor cells and reticular cells (Figure 8).
examination. Other 4 sections of 5µm thickness Bone section at implant coated with HA and
were mounted on positively charged microscopic fibronectin protein for 1 week duration shows area
slides to obtain a greater tissue adherence for of woven bone tissue strong positive localization
immunohistochemistry. The procedure of the IHC of GHR in progenitor osteoblast cell and in
assay adapted by this study was carried out in extracellular matrix (Figure 9).
Oral Diagnosis 33
Bone trabeculae with active primitive bone thickening (corticalization” process was
formation in titanium implant coated with HA and observed, despite the non-functioning of these
fibronectin protein for 2 weeks duration marrow implants in agreement with the finding of
tissue of different sizes showing positive stain are Hammad et al It may be suggested that this
enclosed by anastemosing trabeculae, osteoblast
bone response constitutes just a step in the entire
seen at the peripharyes and huge neumerous of
bone healing process even in the absence of load.
osteocytes are located within bone matrix , both
Immunohistochemical findings, osteocalcin of
types of cells show positive stain, the trabeculae
that Osteocalcin are positively expressed in both
of bone itself are stained negatively (Figure10).
coated and uncoated implants and for all coating
After six weeks of implantation mature lamellated
material in different intervals period. Bone
bone is deposited at implant site, it shows
marrow tissue is positively stained indicating
negative DAB stain for GHR, some osteocytes are
osteocalcin protein localization. Strong positive
embedded within bone matrix osteon canal and in
expression of osteocalcin was noted with agroup
endostium area stain positively (Figure 11).
of implant coated with FN and also coated with
HA (HEF). This is in agreement with
DISCUSSION Timothy et al and Tardieu (10) they revealed that
(5)
In this study we use biological organic material
coating of implant with FN protein enhanced
represented by fibronectin coated the implant and
osteoblastic differentiation and minerlization in
others used in combination with HA. The general
bone marrow stromal cell, also FN. Protein
histologic finding abserved that all surface
function to stimulate bone formation by moving
investigated were biocompatible and
adult stem cells from a site far away from the
osseoconductive. Fibronectin protein is biological
surrounding of the implant into the implanted site
glycoprotein act as osseoinductive material, it
by chemotaxis so as to differentiation into
enhance recruitment of progenitor cell to its area
osteoblasts .In 6 weeks duration, osteocalcin
and activate its differentiation into osteoblast cells
shows negative immunohistochemical stain for
once these cells deposit organic matrix specially
localization of , osteocalcin but it shows positive
collagen fiber, the FN will facilitate the adherence
expression on osteoblast lining the surface of
of these cells to fiber, these biological sequence
osteon and when there is area of bone formation.
facilitate and accelerate bone formation
These findings are in agreement with Muramatsu
process
et al, 2005 study which indicated that agreater
Modification effect of HA in coating process that
osteocalcin expression is observed at 14 and 21
enhance progenitor cell to differentiate to
days characterization the periods when intense
fibroblast in addition to osteoblast and also
minerlization of the bone tissue occurs during
reticular cell activation which showed reticular
alveolar bone healing process. In this study GHR
fiber deposition when needs for more
shows positive expression in coated and uncoated
investigation implants in all healing interval periods. In two
These results indicating that active bone week duration osteoid tissue formed around
apposition with strong attachment was achieved titanium implant shows positive localization of
on the surface of implant coated with HA and FN GHR in the formative cell progenitor that are
protein which may be the reason for higher irregularly arranged within primitive bone
removal torque value. The possible explination for formed. After 6 weeks of implantation osteon
these finding is that surface chemistry is canal and in endostium area shows positive
effectively influenced osseointegration and the localization of GHR.
higher torque value may be interpreted as an The differences in the bone reaction between
increase in the strength of bony integration at the coated and uncoated implants not only suggesting
bone, implant interface. This is in agreement a high osteoconductive potential of the coated
within work of Suh et al material but also it’s osteoinductivity, the
The radiographic examination shows increase in osteoconductive action was seen in all coated
the thickness of cortical bone at experimental groups specially for that coated with mixing of
implant sites indicating increased bone formation FN and HA where bioactive properties can be
and maturation around the coated implants for the seen by the presence of fibrovascular tissue,
six weeks duration of implantation. In studied osteoblast activity and expression of bone marker
groups of the present study, following insertion of new bone formation, these finding was in
a biocompatible CpTi implant into cortical bone agreement with Al-Mudarris et al (16) and
the implants were not submitted to any load, in Hammad et al (17)
most of the implants the presence of such
Oral Diagnosis 34
Signaling Domains and Their Associated Transcripts

REFERANCE Molecular and Cellular Biology, 2005; 25(1): 66-77 .
1. Lee JH, Nam H, Ryu HS, Seo JH, Chang Bs, Lee CK.
10. Maher SM, Brown R, Teasdale RD,Noakes PG.
Bioactive ceramic coatings of cancellous screws
Waters. In Vivo Analysis of Growth Hormone
improves the osseointegration in the cancellous bone.
Receptor Signaling Domains and Their Associated
J Orthop Sci 2011; 16:291-7.
Transcripts. Molecular and Cellular Biology 2005;
2. Xiao SJ, Kenausis G, Textor M. Biochemical
25(1): 66-77 .
modification of titanium surfaces. In: Berunette DM,
11. Tardieu P. Process for the preparation of protein
Tengvall P, Textor M, Thomsen P, editor. Titanium in
mediated calcium hydroxyapitite (HAP) coating on
medicin. Berlin : Spreingler Verlay, 2001;417-53.
metal substrate. Patent application number 12/175812
3. Hung J, Li X, Koller GP,. Silvio LD.
Assignee council of scientific and industrial research
Electrohyrodynamic deposition of nan-titanium doped
Internationalclasses: A61L 27/32:A61L27/00 2010.
hydroxyapatite coating for medical and dental
12. Jimbo R, Coelho PG, Vandeweghe S, Schwartz-Fiho
application. J Mater Sci Mater Med 2011; 22:441-496.
HO, Hagashi M, one D, Andersson M, Wennerberg A.
4. Obadia L, Jullien M, Quillards, Rouillion T, Pilet P,
Histological and three-dimensional evaluation of
Guicheux J, Bujoli B, Bouler JM. Na-doped β-
osseointegration to nano structured calcium
tricalcium phosphate: physic chemical and in vitro
phosphate-coated implants. Acta Biomater
biological properties. J Mater Sci Mater Med
2011;21:20-5.
2011;22:593-600.
13. Suh JY Jeung OY, Chio BJ, Park JW. Effects of a
5. Timothy AP, Catherine DR, Kellie LB, Andress JG.
novel calcium titanate coating on the osseointgration
Simple application of fibronectin- mimetic coating
of blasted endosseous implantatsin rabbit tibiae. Clin-
enhances osseointegration of titanium implants. J cell
Oral Implant Res 2007; 17:362-4.
Mol Md 2009; 13(8B):2602-12.
14. Januario AL, Sallum EA, Toledo S, Sallum AW,
6. Caoa T, Henga BC, Yea CP, Liua H, Toha WS,
Nocitif HJ. Effect of Calcitonin on Bone Formation
Robsonb P, Lib P, Hong YH. Osteogenic
Around Titanium Implant. A histometric study in
differentiation within intact human embryoid bodies
rabbits. Braz Dent J 2001;12(3):158-62
result in a marked increase in osteocalcin secretion
15. Hammed TI, Al-Ameer S.S, Al-Zubaydi TL.
after 12 days of in vitro culture, and formation of
Histological and mechanical evaluation of
morphologically distinct nodule-like structures Tissue
electrophoretic bioceramic deposition on Ti 6AL-7Nb
and Cell 2008; 37(4): 325-34.
dental implants. A phD thesis, College of Dentistry,
7. Lee NK, Sowa H, Hinoi E, Ferron M, Ahn JD,
University of Baghdad 2007.
Confavreux C, Dacquin R, Mee PJ, McKee MD, Jung
16. MuramatsuT, Hamano H, Ogami K, Ohta K, Inoue T,
DY, Zhang Z, Kim JK, Mauvais-Jarvis F, Ducy P,
Shimono M,Reduction of osteocalcin expression in
Karsenty G. Endocrine regulation of energy
aged human dental pulp. National Library of Medicine
metabolism by the skeleton. Cell 2007; 130 (3): 456–
2005;38 (11):817-21.
69.
17. AL-Mudarris BA, Salem SAL, Al-Zubaydi TL. The
8. Cool SM, Grunert M, Jackson R, Li H, Nurcombe V,
significance of biometric calcium phosphate coating
Wters MJ. Role of growth hormone receptor signaling
on commercially pure titanium and Ti-6AL-7Nb
on osteogenesis from murine bone marrow progenitor
Alloy.A phD thesis, College of Dentistry University of
cells. Biochem Biophys Res Commun 2005;
Baghdad 2006.
16:338(2):1048-58
18. Hammed TI, Al-Ameer S.S, Al-Zubaydi TL.
9. Jennifer E. Rowland, Agnieszka M. Lichanska, Linda
Histological and mechanical evaluation of
M. Kerr, White M, Elisabetta M. d’Aniello. ,Maher
electrophoretic bioceramic deposition on Ti 6AL-7Nb
SM, Brown R, Teasdale RD,Noakes PG. Waters :In
dental implants. A PhD thesis, College of Dentistry,
Vivo Analysis of Growth Hormone Receptor
University of Baghdad 2007.
Table 1: Summary Statistics for Removal Torque test in different studied and suggested of
coated materials treated along two weeks and six weeks measured continuously
Torque- test
95% Confidence Interval for Mean
Period Material Groups N Mean S.D. S.E. Min. Max.
Lower Bound Upper Bound
After (2) FN+HA R - Control 4 11.11 1.38 0.69 8.91 13.30 10.00 13.13
weeks (HEF) L1 - Coated 4 15.31 1.20 0.60 13.41 17.22 14.38 16.88
After (6) FN+HA R - Control 4 18.28 0.60 0.30 17.33 19.23 17.50 18.75
weeks (HEF) L2 - Coated 4 30.28 0.76 0.38 29.07 31.49 29.38 31.13
Oral Diagnosis 35
Figure 1: Conventional radiographic Figure 2: Positive DAB stain

view for Ti implant coated with HA immunohistochemical localization of
and fibronectin protein for 6 weeks osteocalcin protein in site surface of
shows overhang bone on the implant. titanium implant coated with FN and
Where (C) uncoated and (HEF) HA in rabbit tibia for 3 days duration
coated with fibronectin protein and DAB with haematoxylin counter
hydroxyapatite. stain x 100
Figure 4: View for positive

Figure 3: High power view of previous immunohistochemical localization of
Figure 2 shows positive brown colour osteocalcin protein in nucleous of
for DAB stain for stromal cells to osteoblast active fibroblast cells and in
osteocalcin protein DAB with the extracellular matrix of woven
haematoxylin counter Stain x 200. bone deposite around the titanium
implant coated with FN and HA for 1
week duration in rabbit tibia.DAB
with haematoxylin counter stain x 200.
Oral Diagnosis 36
Figure 5: Immunohistochemical view for Figure 6: High magnification view of

localization of osteocalcin protein in previous Figure 2 shows bone trabeculae
titanium implant coated with FN and HA (negative stain) and the formation and
for 2 weeks duration shows negative stain progenitor between shows positive stain
to calcified bone trabeculae as shown blue DAB with haematoxylin counter stain x
stain) and only the formative cells shows 400
positive stain.DAB with haematoxylin
counter stain x 400.
Figure 7: Immunohistochemical view of Figure 8: View for positive

threads of Ti implant coated with HA and immunohistochemical DAB stain for GHR
FN for 6 weeks duration shows positive in titanium implant surface coated with
DAB stain in osteoblast cells for osteocalcin HA and FN for 3 days duration. DAB with
protein as it occupies the surface lining the haematoxylin counter stain x 200
bone DAB with haemtoxylin counter stain
X200.
Oral Diagnosis 37
Figure 9: Woven bone view of titanium Figure 10: Bone trabeculae view of
implant coated with HA and FN for 1 week titanium implant coated with HA and FN
duration shows positive DAB stain for for 2 weeks duration shows positive DAB
GHR localized extracellular matrix and in stain for GHR localized only on osteocyte
progenitor osteoblast DAB with and osteoblast , while bone itself shows
haematoxylin counter stain x 400. negative stain note the huge numerous
number of osteocyte DAB with
haematoxylin counter stain x 200
Figure 11: Thread view of titanium

implant coated with HA an FN for 6
weeks duration shows negative stain for
GHR in mature bone and only positive in
the area occupied by osteon canal and in
endostium area DAB with haematoxylin
counter stain x 200.
Oral Diagnosis 38
J Bagh College Dentistry Vol. 24(2), 2012 Evaluation of 900 mhz
Evaluation of 900 mhz mobile phone effects on palate and

tooth germ development in mouse embryo (histological &
immunohistochemical study)
Faten H. Berto, B.D.S. (1)
Athraa Y. Al-Hijazi, B.D.S., M.Sc., Ph.D. (2)
ABSTRACT
Background Mobile telephones, sometimes called cellular phones (GSM, Global System for Mobile Communication)
or handies, are now an integral part of modern telecommunications. In some parts of the world, they are the most
reliable or only phones available. In others, mobile phones are very popular because they allow people to maintain
continuous communication without hampering freedom of movement.This study was carried out to evaluate the
effects of 900 MHz mobile phone on palate and tooth germ development in mouse embryo for the period of (16th
day, 18th day intrauterine life and one day postnatal life).
Materials and Methods Thirty pregnant Bulb-c Albeno Swiss female mouse (2-3 months of age, 100-125 gm of weight),
were used in the present experiment. Those mice were divided into three groups. The first group consisted of 6
pregnant mice were assigned as a control group. The second group consisted of 12 pregnant mice were exposed to
mobile phone radiation for 60 minutes daily and the third group consisted of 12 pregnant mice were exposed to
mobile phone radiation for 120 minutes daily starting from the zero day of gestation till the day of scarification. The
embryos of mice; were obtained at different period of gestation (At 16th day I.U.L., 18th day I.U.L.,and One day old
postnatal period).
Results Histological examination and immunohistochemical evaluation for CD34 expression were done for all animals
including control group showed that mobile phone (EMF radiation) with 900 MHz in short exposed period (one hour)
can stimulate tooth germ cells as it was shown,an early appearance of tooth germ in cap stage at 16th day I.U.L and
positive expression of CD34 marker on dental tissue.
Conclusion In this study we investigated an important point that the effects of mobile phones concerned on
mesenchymal germ cell rather than ectodermal germ cell which represented by positive reaction of CD34 on
mesenchymal cell of dental sac ,bone and cartilage. Increment in time exposure to EMF radiation emitted from
mobile phone for 2 hours duration showed retardation in tooth development with obvious reduction in size of the
mice.
Key words: Radiofrequency radiation, tooth germ, mobile phone. (J Bagh Coll Dentistry 2012;24(2):39-46).
INTRODUCTION
Radiofrequency fields are part of electromagnetic Mobile or cellular phones are now an integral part
spectrum. For the purpose of international of modern telecommunications.
electromagnetic fields (EMF) project. Such fields In many countries, over half the population use
are defined as those within the frequency range mobile phones and the market is growing rapidly.
(10MHz-3000MHz). Common sources of At the end of 2009, there were an estimated 4.6
radiofrequency fields include: mobile telephones, billion subscriptions globally. In some parts of the
television broadcast, microwave ovens, medical world, mobile phones are the most reliable or the
diathermy, radar, satellite links, microwave only phones available. Mobile phones
communications and sun (1). communicate by transmitting radio waves through
Mobile phone, some time called cellular phone a network of fixed antennas called base stations.
(GMS, Global system for mobile communication), Radiofrequency waves are electromagnetic fields,
mobile telecommunication system has been and unlike ionizing radiation such as X-rays or
widely used all over the world. In others, mobile gamma rays, can neither break chemical bonds
phones are very popular because they allow nor cause ionization in the human body.
people to maintain continuous communication Widespread concerns have been raised about the
without hampering freedom of movement (2). Cell possibility that exposure to the radiofrequency
phones operate within the frequency band of 800 (RF) fields from mobile telephones or their base
MHz, 900 MHz and 1800 MHz and the latest 3G stations could affect people’s health Various
technology works between 1900 -2200 MHz Over epidemiological and experimental studies have
the past two decades, mobile telecommunication been carried out and the results have shown to
system has been widely used all over the world. have a close relation between biological effects
and Electromagnetic radiation (3). A large number
(1) MSc. Student, Department of Diagnosis, College of Dentistry, of studies have been performed over the last two
University of Baghdad. decades to assess whether mobile phones pose a
(2) Professor, Department of oral Diagnosis, College of Dentistry, potential health risk. To date, no adverse health
University of Baghdad.
effects have been established as being caused by
Oral Diagnosis 39
mobile phone use. Although there is a vast body components (lateral) &frontonasal prominence
of material on the biological effects of (midline). The secondary palate can also be
radiofrequency fields, current risk assessment is divided in two anatomical parts: Anterior hard
still limited. There are several hypotheses and palate &Posterior soft palate. The oral side of the
results of biological effects such as thermal palate is covered with a squamous stratified
effects, genetic and carcinogenetic effects and epithelium. The surface of the hard palate of most
cancers related investigations. The use of mobile mammalian species is further thrown into a series
phones operating in the 900MHz frequency band of palatal ridges or rugae palatinae that are
is very widespread and ever increasing (4). Tissue transversal ridges. (10). Oral tissues are one of the
heating is the principal mechanism of interaction important parts of head/body that absorbs the
between radiofrequency energy and the human radiation emitted from mobile phones, there were
body. At the frequencies used by mobile phones, a lot of studies in that the effects of mobile phones
most of the energy is absorbed by the skin and on head were investigated; but did not encounter
other superficial tissues, resulting in negligible any histological study focused on the effects on
temperature rise in the brain or any other organs tooth development. Therefore, the goal of this
of the body. A number of studies have study is to investigate and to research an answer
investigated the effects of radiofrequency fields to the question of have mobile phones effects on
on brain electrical activity, cognitive function, palate and tooth germ development.
sleep, heart rate and blood pressure in volunteers.
To date, research does not suggest any consistent MATERIALS AND METHODS
evidence of adverse health effects from exposure Handsets of global system for communication
to radiofrequency fields at levels below those that (GSM) mobile phone of the same brand and
cause tissue heating. Further, research has not model were used (Nokia 1100). Thirty pregnant
been able to provide support for a causal Bulb-c Albeno Swiss female mouse (2-3 months
relationship between exposure to electromagnetic of age, 100-125 gm of weight), were obtained
fields and self-reported symptoms, or from the animal house of the national center for
“electromagnetic hypersensitivity” (5). Concern drugs control and research, used in the present
has been expressed for number of years that experiment. The pregnant female was separated
exposure to radiofrequency (RF) fields emanating from male in a different special Plexiglas cages
from mobile phones and radar and television surrounded by the edges of the aluminum (Width
transmitters may increase the incidence of cancer 15 cm and height 10 cm); food pellets, bedding
in humans (6). Epidemiological studies have not and environmental conditions (temperature,
indicated an increased cancer risk, but the humidity and ventilation) were equal among all
methodology and exposure assessment are animals. Those mice were divided into three
generally considered to have been suboptimal. groups. The first group consisted of 6 pregnant
Several reports have indicated that mice were assigned as a control group, nothing
electromagnetic fields (EMF) enhance free radical applied to mice in this group and they completed
activity in cells. Free radicals kill cells by their life cycle in the cage during the study period.
damaging macromolecules, such as DNA, protein The second group consisted of 12 pregnant mice
and membrane (7). were exposed to mobile phone radiation for 60
Tooth development or odontogenesis is the minutes daily and the third group consisted of 12
complex process by which teeth form from pregnant mice were exposed to mobile phone
embryonic cells, grow, and erupt into the mouth. radiation for 120 minutes daily starting from the
Although many diverse species have teeth, non- zero day of gestation till the last day of
human tooth development is largely the same as scarification .The embryos of mice; were obtained
in humans. The tooth bud (sometimes called the at different period of gestation (At 16th day I.U.L.,
tooth germ) is an aggregation of cells that 18th day I.U.L., and One day old postnatal period).
eventually forms a tooth. These cells are derived Histological preparation:
from the ectoderm of the first branchial arch and Sagittal sections through the head of the embryos
the ectomesenchyme of the neural crest. The tooth were separated from the body and preserved in
bud is organized into three parts: the enamel 10% buffed formalin for 72 hours for histological
organ, the dental papilla and the dental follicle (8). examination. The specimens were washed well in
The palate has two key stages of development running water, then dehydrated through graded
during embryonic (primary) and an early fetal series of alcohols (50, 60, and 70 up to absolute
(secondary) involving the fusion of structures and alcohol then xyline), cleared and embedded in
a key epithelial to mesenchymal transition (9). The paraffin wax. Serial sections of specimens were
primary palate is formed by two parts: maxillary put at 5 microns by Reichert –Jung Microtome,
Oral Diagnosis 40
and stained with Hematoxylin and eosin .All

sections were examined under light microscope.
Immunohistochemistry:
This study was performed on all formaline fixed
paraffin embedded blocks for all control and
experimental groups of different coating materials
and techniques using CD34 with
Imunohistochemistry Detection Kit, HRP, Mouse Figure 4: distribution of CD34 marker in the
primaries (mouse tissue), BioAssayTM. progenitor cell and blood vessel (arrow) in
primitive mouth cavity.AEC stain X100
RESULTS B-Experimental group 1:
Clinical findings
Histological feature for upper and lower jaw
A- In the present study the pregnant mice which
showed tooth germ cap to bell stage .Complete
were exposed to EMF radiation of mobile phone
fusion of secondary palate but still nasal septum
for a period of 2 hours, showed a retardation in
not fused with it, and tongue is high in position
delivery time as for control group, pregnant mice
filled the oronasal space. Lower tooth germ
deliver embryo at 20-21 days of gestation period,
illustrate stage (cap to bell) in development and
while experimental group which were exposed for
showed enamel organ with 4 layers inner enamel
2 hours showed to be delivered in 28-30 days.
epithelia ,outer enamel epithelia ,stellate reticulum
B-Clinical observation also illustrates different in
,stratum intermedium ,dental papilla, and dental
the size of the embryos .Control group and
sac (Figure 5). Positive expression of CD34 was
experimental group one showed to be
illustrated in dental sac, in mesenchymal cell
approximately the same, their size range from
while negative expression was reported in enamel
(14-16 mm3) in 18th day, while experimental
organ cell (Figure 6).
group two records (6-8mm3).One day old mice for
control and experimental group one, their size
range from (40-50 mm3), while for experimental
group two (30-35 mm3).
Histological and immunohistological findings

At 16th day I.U.L.
A-Control group: Figure 5: lower tooth germ at cap to bell
Histological sections of the embryo head showed stage.H&EX200
upper tooth germ to be in bud stage represented
basal cell and central polyhedral cells (figure 3).
CD34 expression was detected in the progenitor
cell in primitive mouth cavity of the mice (Figure
4).
Figure 6: positive reaction of CD34 in dental

sac (DS).AEC stain X200
C-Experimental group2:
Figure 3: upper tooth germ in bud stage A histological finding recorded a primitive mouth
showed: basal cell (BC), central cell cavity thickening in oral epithelia, underneath it
polyhedral in shape (arrow), dental lamina ectomesen-chymal tissue. Fig (7).Negative
(DL).H&EX200 expression of CD34 marker detected on cells of
oral epithelia and ectomesenchymal cells. (Figure
8).
Oral Diagnosis 41
B-Experimental group 1:
Histological findings illustrate tooth germ at
advance bell stage with apposition of dentin.
Numerous blood vessels detected in the dental
pulp. Figure(11). Positive expression of CD34
was localized in dental papilla and dental sac and
in area of cell bone formation, while negative
Figure 7: primitive mouth cavity of embryo AEC stain detected in enamel organ (Figure 12).
mouse 16th day intrauterine .H&E X200.
Figure 11: tooth germ showed odontoblast

(OD), dentin (D) and preameloblast
Figure 8: Negative immunohistochemical (PAB).H&EX200
expression for CD34 on cells of oral
epithelium (OEP), and ectomesenchymal cell
(EMC).AEC X400
At 18th day I.U.L

A-Control group:
Histological section showed tooth germ at bell
stage for the lower jaw and tooth germ in cap
stage for the upper. Differentiation of dental Figure 12: positive reaction for CD34
papilla to odontoblast cell can be detected but localized in dental pulp (DP) and in dental
with no feature of apposition of dentin (Figure 9). sac (DS) around.AECX200
Immunohistochemical reaction for localization of
CD34 in tooth germ shows moderate positive C-Experimental group 2:
reaction in dental sac and weak position in dental This group illustrated tooth germ in bud stage in
papilla (Figure 10). upper jaw and disturbed and displacement in cells
of basal layer and central layer. While lower tooth
germ showed tooth development in cap stage also
displacement and disturbances in the cell micro
architecture were reported in figures 13. Negative
expression of CD34 was illustrated in all dental
layers of tooth germ except demarked line of
basement membrane showed positive stain
Figure 9: upper tooth germ in cap to bell (Figure 14).
stage showed dental papilla (DP), inner
enamel epithelia (IEE), and dental lamina
(DL).H&E X100
Figure 13: Cross section in primitive mouth

showed dental lamina (DL), enamel organ
(EO), sign of displacement
Figure 10: Immunohistochemical reaction (arrow).H&EX200
for localization of CD34 in tooth germ
showed positive reaction in dental sac area
(arrow),and weak positive reaction in dental
papilla(DP).AEC X200
Oral Diagnosis 42
Figure 14: color demarked basement Figure 17: tooth germ .Showed odontoblast
membrane(arrow).AEC stain X400 (OD), dentin (D), enamel (E) and ameloblast
(AB).H&EX400
At one day old (postnatal life)
A-Control group:
Histological examination for all sections
illustrated upper tooth germ at early bell stage and
lower tooth germ at advance bell stage (Figure
15). Immunohistochemical view for the tooth
germ illustrated negative reaction for CD34 in
enamel organ and positive reaction in dental sac
and endothelial cell of arteriol (Figures 16 A &B). Figure 18: positive reaction for CD34 in
Dental sac (DS), blood vessels showed strong
positive reaction stain (arrow) ,upper limit of
the figure showed negative stain (blue)for
enamel organ(EO).AEC stain X400
C-Experimental group 2:
Histological findings illustrateed tooth germ at
bell stage (Figure 19).Tooth germ illustrated
Figure 15: tooth germs upper one in early negative expression for CD34 in all dental layers
bell stage(EBS),lower in advance bell stage except basement membrane and in dental sac area
(ABS), tongue (T) at the side.H&EX100 showed weak positive of AEC stain (Figure 20).
A B
A B Figure 19: A: tooth germ at bell stage in
Figure 16: A :Negative reaction for CD34 in neonatal mouse Showed odontoblast (OD),
enamel organ (EO), positive reaction in preameloblast(PAB),stellate reticulum(SR)
dental sac (DS) and bone formation area ,and dental papilla(DP).H&EX200. B:
(B).AEC stain X200 B: View for dental sac positive reaction of CD34, illustrated in
area showed blood vessels arteriol, basement membrane (arrow) separates
endothelial cell (arrow) stain positive for odontoblast (OD) from ameloblast (AB).
CD34 marker ..AEC stain X200 AEC stain X200
B-Experimental group 1:
Histological examination illustrateed apposition
DISCUSSION
Radiofrequency waves emitting from cellular
of dental hard tissue enamel and dentin with their
phones and base stations has emerged as a fact
formative cell ameloblast and odontoblast (Figure
which affect increasing number of people by the
17). Tooth germ showed positive stain high
time. As cellular phone usage gets more
lightened on dental sac cell and blood vessels,
widespread, electromagnetic radiation has become
while enamel organ illustrated negative stain
an important health problem, which was also
(Figure 18).
reported by the previous studies suggesting the
harmful effects of radiofrequency waves on
human health (11-14). So far, there has been a
Oral Diagnosis 43
controversy whether EMF has a negative effect on related with changes in Mg and Zn amounts.
health or not. Any embryo toxicity of EMF in However, these findings suggested the possibility
pregnant mothers raises public apprehension. of GSM-Modulated 900 MHz radiation to play an
Concerns about potential susceptibility of embryo, important etiological role in mineralization
fetal, newborn and the juvenile to EMF are process. Kaya et al 2008 studied the effects of
comprehensible due to the immaturity of all radiofrequency radiation by 900 MHz mobile
organs in their developing stages. A large number phone on periodontal tissues and teeth used
of in vivo studies have been carried out in experimental rat group exposed to mobile phone
mammals reported only slightly effects on fetus radiation for 2 h/day, 7 days/week, and 10
(15, 16)
. months. At the end of the experiment, the
The present results showed an early tooth histopathological evaluation showed abnormal
development for embryo aged 16th day changes like vasodilatation and focal bleeding
intrauterine life when its mother was exposed for area were determined in periodontal ligament,
one hour to radiation, upper and lower teeth alveolar bone , gingival and pulpa among some
showed tooth germ at cap stage with well individuals.
developed, fused palate, well developed ridges. In It is well known that embryonic tissue be
comparison to control, which illustrated tooth immature regarding to tooth germ layer be very
germ in bud stage? On the other hand exposed for sensitive and susceptible to injury especially to
two hours duration to radiation affected the tooth chemical material like drug and when exposed to
development in versus way, as the results showed radiation in which its effects depend on its
retardation in development of teeth and palate. duration and frequency. The most possible effects
Tooth germ recorded to be missed in 16th day of of RF fields on cell receptors alter the protein
gestation and hardly oral ectodermic thickness conformation by Changes in binding to cell
was detected. These results could be explained on receptor proteins. Chiabrera et al in 2000 found
the followings: that significant changes in the probability of
Electromagnetic waves may interact with ligand binding could be produced by the
biological tissues through either thermal or modulation of the well shape by RF electric fields
nonthermal mechanisms. The components of the below guideline values. Therefore, in these results
biological system, like those of any other system, it seems that exposed for 2 hours daily be harmful
are constantly subjected to the random fluctuating to the progenitor cells, while 1 hour seems to
electric and magnetic fields associated with the enhance and act as stimulator to the stem cells.
random motion of charges known as Brownian Moreover the pathologies such as oedema,
motion or thermal noise. As electromagnetic interstitial hemorrhagia, collagen decomposition,
fields with high frequency can be hazardous in dearrangement of specialized cells such as
terms of thermal changes, long time exposure to odontoblast ameloblast ,osteoblast were not
low frequency electromagnetic waves can lead to detected in dental tissue of the embryo mice of the
some unexpected biochemical changes in the present study exposed for EMF of both
body (17). As the frequency interval of analogue duration(60,120 min.) These results disagreed
phones is between 800 and 900 MHz, digital with results of Kaya et al 2011, who used low
phones work between 1850 and 1990 MHz frequency magnetic field on pulp tissue of rats.
frequencies (18). All review of literatures studied They found it affected odontoblast and fibroblast
mostly on body tissues. But did not find any cells and they attributed to un accurate intensity of
studies regarding the effects of EMF on tooth EMF that be used on the dental tissue of their
development, only few of the studies conducted experiment.
by Adiguzel et al in 2008 used experimental rat The present result illustrated an early deposition
group exposed to GSM-Modulated 900 MHz of dental hard tissue in experimental group
radiofrequency radiation for 2 hours per day exposed to EMF for one hour at 18th day of
during ten months. At the end of the exposure gestation and at one day of neonatal life in
period, the contents of some elements as Ca, Mg, comparison to control and the study suggested
Zn, and P were measured in the oral tissue. The that exposure for short duration activate
measurements were performed by Atomic specialized dental cells (odontoblast and
Absorption Spectrophotometry (AAS). However, ameloblast) to deposit organic matrix of enamel
phosphorus content of teeth was measured by and dentin, and may play a role in mineralization
ultraviolet spectrophotometer (UVS). The results and maturation processes. For the experimental
showed positive change evidence in rat’s teeth, group two at the same above periods, it has versus
and it supports the hypothesis that GSM- action, it retards development and disturbs the
Modulated 900 MHz radiofrequency radiation is differentiation of specialized dental cells either by
Oral Diagnosis 44
affected its functions in formation of hard tissues one hour act as stimulator and activates cell
of embryo or due to hormonal changes of proliferation and differentiation. Dental papillae
pregnant mother. Therefore; these results, which showed weak positive in expression for CD34 and
have been obtained from study on animals, should that related to its localized ability to form multi-
be further investigated and mainly for specialized tissue as in dental sac, it only formed
biochemical mineral analysis of dental tissue. At pulp although it contains blood vessels, nerves,
the same time we didn’t encounter any progenitor mesenchymal cells but not extended
histopathologic studies focused on embryo like dental sac. The negative immunoreactions of
development concern with tooth germ and CD34 marker of enamel organ cells attributed to
palatine growth. Therefore; this study may its ectodermal embryonic origin.For experimental
consider the first one in this field. group exposed for two hours to EMF, it showed
CD34 is a well-known marker of progenitor cells only positive reaction in basement membrane, as a
of blood vessels, stromal tissues, bone cell and basement membrane is an acellular structure,
mesenchymal cells. Thus, CD34-positive cells made up of neutral polysaccarides, fibronectin,
have recently been used clinically in the field of laminin, type IVcollagen and as CD34 is a 110-
vascular and orthopedic biotechnology because of kDa transmembrane glycoprotein present on stem
their capacity to assist regeneration of injured cells. Therefore its positive immunoreaction may
tissues. However, as known, the in situ detection be related to cross reaction and close similarity
of CD34positive cells has not yet been described with chemical components of antigens. So its
in the fetus, with the exception of a few organs, expression is not clear and it needs more
Abe et al 2011 study expression of CD34 in investigations. Nourbakhsh et al 2011 studied in
human mesenchymal tissue of fetuses (9-15 vitro the Stem cells from human exfoliated
weeks of gestation). They detected CD34-positive deciduous teeth (SHED) which are highly
structures as a vessel-like appearance and were proliferative, clonogenic and multipotent stem
regularly arrayed in the viscera, nerves and lymph cells with a neural crest cell origin. Expressed
nodes, in the body wall and extremities. antigens CD146, CD45, CD90, CD106 and
In the present study, immunohistochemistry for CD166, but not the hematopoietic and stem cell
CD34 expression in embryonic tissue in different markers, CD34 and CD31was detected. These
periods of gestation of a mice (16th, 18th and one results were disagreement with our findings.
day postnatal period) was used to include all Several reviews on the issue of possible adverse
primitive stem cells suspected to be involved in health effects of mobile phones have been
the formation of the face including teeth, jaws, published (25). The fact that some environmental
palate, tongue and other related structures and factors like GSM-Modulated 900 MHz
because it is the first research till the time of radiofrequency radiation fields may have some
prepared thesis studied in vivo dental cell harmful effects continues to arouse more interest
immunoreactions with CD34 markers. The especially in last two decades. Some literature has
present study illustrateed the followings: strong been reported that environmental effects such as
positive expression of CD34 on cells of dental GSM-Modulated 900 MHz radiofrequency
sac, weak positive on cells of dental papilla and radiation may affect health status in accordance
negative immunoreactions for enamel organ cells with the altered physiological conditions (26).
to CD34, in all studied periods and concern to For this reason, further studies are needed to
experimental group of one hour duration. These reveal the effects of environmental factors on oral
results could be explained on the facts that dental tissues and tooth development more clearly.
sac is an ectomesenchymal tissue derived from
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Oral Diagnosis 46
J Bagh College Dentistry Vol. 24(2), 2012 Chronological ِage estimation
Chronological ِage estimation in adolescent and young

adult subjects in relation to mandibular third molar
development using digital panoramic image
Jaafar J. Attar, B.D.S. (1)
Jamal Ali AL-Taei, B.D.S., M.Sc. (2)
ABSTRACT
Background: Predicting chronological age in adolescents and young adults can be crucial in Medico legal contexts
and the third molar is the only developing tooth during this period that used to determine chronological age.
The purpose of this study was to estimate the chronological age based on the stages of mandibular third-molar
development following the eight stages (A–H) method of Demirjian et al
Materials and methods: The sample consisted of 436 Iraqi adolescents and young adults subjects have been chosen
with known chronologic age (range, 14–24 years) and sex (162 males and 274 female), digital panoramic
radiograph had been taken for each examined subject, Demirjian’s grading has been used to assess third molar
development
Results: Statistically significant differences (P _ 0.05) in third-molar development between males and females were
revealed regarding the development stages D,E and F. Third-molar genesis was attained earlier in males than in
females. Statistical analysis showed a strong correlation between age and third-molar development for males (r 2 _
0.91) and for females (r 2 _ 0.87).
Conclusion: It was concluded that the use of mandibular third molar development stages using Demirjian method
can be considered as good valuable chronological age indicators in adolescents and young adults
Keywords: Third molar; Chronological age; Age estimation. (J Bagh Coll Dentistry 2012;24(2):47-50).
INTRODUCTION Therefore developing 3rd molar is the only

In the past decade the number of unidentified reliable biological dental indicators variable and
cadavers and human remains as well as the readily assessable from dental radiographs during
number of remains lacking age documentation adolescence and the transitional period to
and therefore requiring age determination has adulthood, Indeed a great variation in position,
increased. This requires age calculation, not only morphology, and time of formation(6,7,8) .Up to
for differentiating the juvenile from the adult now several studies have been undertaken in
status in criminal law cases, but especially when different populations these studies show that 3rd
determining the age of a crime victim and also for molar development varies slightly between
estimating chronologic age in relation to school different populations, making population-specific
attendance, social benefits, employment, and studies necessary. Recently, for different ethnic
marriage (1,2). groups, numerous reports have been published on
Method of chronological age estimation in the evaluation of third-molar development (9, 10).
adolescents and young adults may be including Panoramic radiography is a radiological
radiographical examination of the hand and wrist, technique for producing a single image of the
the medial clavicular epiphyseal cartilage, and facial structures that include both the maxillary
finally 3rd molar development observations (3, 4, 5). and mandibular dental arches and their supporting
But compared to bone development, 3rd molar structures. Digital radiography is considered to be
development are less affected by variation in a great enhancement to the diagnostic radiography
endocrine and nutritional status, and in hand and due to its radiation dose reduction, improved
wrist development it is completed around the age image properties, improved storage and
of 18 while 3rd molar development continues until transportability of the
the early twenties when the development of Image and reduce equipment and time needed to
almost permanent teeth may be completed, and produce a superior image (11).
regressive changes in teeth with increasing age The aim of this study was to estimate
may not yet appear at that age. chronological age and gender in adolescent and
young adult subjects based on stages of
mandibular third molar according to Demirjian
method using digital panoramic image.
MATERIALS AND METHODS

(1) M.Sc. Student, oral and maxillofacial radiology, oral diagnosis Samples selection:
Department, College of Dentistry, Baghdad University. In this cross-sectional study, dental panoramic
(2) Assistant Professor, oral diagnosis Department, College of
Dentistry, Baghdad University. image of 450 Iraqi subjects with known
chronologic age and sex were selected.
Oral Diagnosis 47
Selection criteria included the following: All statistical analyses were performed using
• Adolescent and young adult Subjects; SPSS version 15.0. (Statistical Package for Social
• Well nourished and free of any known Sciences)
serious illness; To test the reproducibility of the assessments of
• Normal growth and development and dental dental development stage, two investigators
conditions, for example, no impactions, reevaluated randomly selected panoramic
congenital absence, or transposition of teeth. radiographs from 10% of the same male and
Exclusion criteria excluded the following: female subjects after the first evaluation. Inter-
• Image deformity affecting third molars; and and intra observer agreements were determined
• Panoramic image showing obvious dental using the Binominal–test (non-parametric test)
pathology.
Fourteen films were excluded for poor RESULTS
radiographic quality, and for agenesis of the third Repeated scorings of a subsample of 40
molars. The final sample consisted of 436 radiographs indicated no significant intra- or inter
Panoramic image from Iraqi individuals of known observer differences (P_0.05). Intra observer
chronologic age and sex. Mean age range of the consistency was rated at 98%, whereas inter
436 patients for both genders was (14- 24 years). observer agreement was 95%.
All assessments were performed by digital The third-molar formation process was examined
panoramic image in computer to ensure contrast in both sexes, and the mean ages and standard
enhancement of the tooth images. deviations for the Demirjian stages are described
Examination and classification covered the in (Table 1).
development phase of the left mandibular molar Data for Demirjian stages A, B and C was omitted
third and, when not present, the Contra lateral from the study because no teeth in stages A and B
molar was considered. were noted and less than 1% was noted in stage C
Tooth calcification was rated according to the for the present study
method described by Demirjian et al 12 in which In both male and female sample groups there is
one of eight stages of calcification, A to H, was strong positive relation ship between the dental
assigned to the third-molar tooth (Figure 1). development stage of mandibular third molar and
chronological age (p<0.001, for both sexes)
Statistically significant differences (P _ 0.05)
were revealed in third-molar development
between males and females regarding the
calcification stage D and stage E. These
differences indicated that third-molar genesis
attained the Demirjian formation stages earlier in
males than in females.
Figure1: panoramic image shows third Table 1: Descriptive statistic of both genders
molar development. Sex Male
Stages Mean SD
The first four stages (A–D) show crown formation D 14.40 0.627
from the beginning of cusp calcification to E 15.79 1.503
completed crown, and the second four (E– H) root F 17.85 1.405
formations from initial radicular bifurcation to G 19.00 1.275
apical closing. H 21.32 1.561
Descriptive statistics were obtained by Sex Female
calculating the means, standard deviations, D 15.09 1.460
and range of the chronologic ages for the eight E 16.66 1.250
stages of dental development. F 18.07 1.557
Statistical analyses were performed using the G 19.46 1.444
Student's t-test between sex and age. ANOVA test H 21.36 1.314
was used to test the statistical significance of
difference in mean between developmental stages DISCUSSION
groups of mandibular molar.Pearson's correlation Chronologic age estimation by tooth development
coefficient to test statistical significance, direction has been used over a long period. Tooth
and strength of linear correlation between 2 development is an accurate measure of
quantitative normally variables. chronologic age that seems to be independent of
Oral Diagnosis 48
exogenic factors such as malnutrition or disease However, other researchers have demonstrated
(13-15).
similar mean age values and distributions for
The third-molar calcification stage is one of the sexes (10, 24,25).
few tools that can be used to assess age when The stage of development of the third molar has a
development is nearing completion during practically linear relation to the age of the
adolescence when the third molar is the only subjects, whether male or female. Statistical
remaining variable dental indicator (16). analysis shows a stronger correlation for male (r
The differences between populations, the 2_0 .91) than for female (r 2 _0 .87) subjects.
different methodology, and the dissimilarity These results also agree with studies on other
among observers are other important populations 9.
shortcomings. In the present study, to overcome
some of these shortcomings, all selected subjects REFERENCES
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using eight stages according to the method of Schutz HW, Kaatsch HJ, Borrman HI. Age estimation:
Demirjian et al.12 a range of different the state of the art in relation to the specific demands
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is available. 36.
2. Willems G. A review of the most commonly used
In the past, different classifications were dental age estimation techniques. J Forensic
presented by Gleiser and Hunt, 17 Moorrees et al, Odontostomatol 2001; 19: 9–17.
18
Kohler et al.19 and Kullman et al, 20 However, 3. Greulich WW, Pyle SI. Radiographic Atlas of Skeletal
some of these classifications identify a large Development of the Hand and Wrist. Stanford, CA:
number of stages that are hard to delimit from Stanford University Press; 1959.
each other. Demirjian et al12 presented a 4. Kreitner KF, Schweden FJ, Riepert T, Nafe B, Thelen
M.,Bone age determination based on the study of the
classification distinguishing four stages of crown medial extremity of the clavicle. Eur Radiol 1998; 8:
development (stages A–D) and four stages of root 1116-22.
development (stages E–H). The system avoids 5. Olze A, Schmeling A, Taniguchi M, Maeda H, Van
any numeric identification of stages so as not to Niekerk P, Wernecke KD, Geserick G. Forensic age
suggest that the different stages represent estimation in living subjects: the ethnic factor in
processes of the same duration. The stages wisdom teeth mineralization. Int J Leg Med 2004;
118:170–3.
proposed by Demirjian et al12 are defined by 6. Engstrom C, Engstrom H, Sagne S. Lower third-molar
changes of shape, independent of speculative development in relation to skeletal maturity and
estimations of length. chronological age. Angle Orthod 1983; 53:97–106.
Dhanjal et al 21 investigated the reproducibility of 7. Zeng DL, Wu ZL, Cui MY: Chronological age
different radiographic stage assessment of third estimation of third molar mineralization of Han in
molars and concluded that the method of stage southern China. Int J Leg Med 2010; 124:119–23
8. Willems G: A review of the most commonly used
assessment of third molars developed by dental age estimation techniques. J Forensic
Demirjian et al 12 performed best not only for Odontostomatol 2001; 19:9-17.
intra- and inter examiner agreement, but also for 9. Prieto JL, Barberia E, Ortega R, Magana C.
the correlation between estimated and true age. Evaluation of chronological age based on third-molar
Therefore, this classification seemed to be the development in the Spanish population. Int J Legal
most appropriate for our study. Med 2005;119:349–54
10. Bolan˜os MV, Moussa H, Manrique MC, Bolan˜os
In the present study examined the mean ages of MJ. Radiographic evaluation of third-molar
each stage for male and female patients development in Spanish children and young people.
statistically significant differences (P_0.05) in Forensic Sci Int 2003; 133: 212– 9.
third-molar development between male and 11. White SC, Pharoah MJ. Oral Radiology Principles and
female subjects were revealed regarding Interpretation, 6th ed. China: Mosby Company; 2009.
calcification stages D and E. 78-100.
12. Demirjian A, Goldstein H, Tanner JM. A new system
These significant differences indicated that third- of dental age assessment. Hum Biol 1973; 42: 211–27.
molar genesis in males attained these Demirjian 13. Nambiar P, Jaacob H, Menon R. Third-molars in the
formation stages 6 to 8 months earlier than in establishment of adult status—a case report. J Forensic
females. Odontostomatol 1996; 14: 30–3.
This observation was consistent with previous 14. Kullman L. Accuracy of two dental and one skeletal
studies, which report that the mean age at some of age estimation method in Swedish adolescents.
Forensic Sci Int 1995; 75: 225–36.
the development stages was lower for males than 15. Melsen B, Wenzel A, Miletic T, Andreasen J, Vagn-
for females in the following populations: Hansen PL, Terp S. Dental and skeletal maturity in
Hispanics, 22; Belgian whites, 23 Swedes, 20 or adoptive children: assessments at arrival and after one
people of Spanish origin9. year in the admitting country. Ann Hum Biol 1986;
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Oral Diagnosis 49
16. Tanner JM, Whitehouse RH, Marshall WA, Healy

MJR, Goldstein H. Assessment of Skeletal Maturity
and Prediction of Adult Height (TW2 Method).
London, England: Academic Press; 1975.
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G. Comparative study on the chronology of third
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Entwicklung des Weisheitszahnes als Kriterium der
Lebensalterbestimmung. Ann Anat. 1994; 176:339–
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chronological age. Swed Dent J 1991; 15:15–22.
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1202 orthopantograms to evaluate the potential of
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Oral Diagnosis 50
J Bagh College Dentistry Vol. 24(2), 2012 Diagnosis of the angular
Diagnosis of the angular hyperkeratotic lesions and the

incidence of the etiologic factors
Jamal N. Ahmed, B.D.S., M.S., Ph.D. (1)
ABSTRACT
Background: Hyperkeratotic lesions located at the angle of the mouth are common among patients attending
dental clinics. Most dentists are unaware of it since the patients are not seeking care. The purpose of the present
study was to find out the incidence of the diagnosed lesions and their relation with the etiologic or initiating factors.
Materials and methods: A total of (112) patient’s (62) males and (50) females having angular hyperkeratotic lesions
were selected from patients attending the dental clinic in Baghdad dental school. The clinical diagnosis and the
progression of the lesions were conducted by using 1% toluidine blue stain to confirm the premalignant potentials
and to delineate the margins of the lesion for the biopsy. Microscopic examinations were done for the confirmation
of the final diagnosis. The associating factors like smoking, alcohol, dental irritation, prosthesis, systemic diseases, and
angular chelitis were recorded in the patient information sheet for the result analysis.
Results: The results showed that the benign hyperkeratotic lesions were the higher (36.6%) in distribution, while the
malignant neoplasms were the 2nd (25.89%) in frequency, followed by premalignant lesions (21.42%), lichen planus
(12.5%), and benign growth (3.57%). Smoking habit was the most common associating factor (54.6%), followed by
angular chelitis (48.2%), dental irritation (43.7%), systemic diseases (35.7%), dental prosthesis (28.5%) and alcohol
consumption 0.05%.
Conclusion: The hyperkeratotic lesions occurred in a wide range of ages. The benign lesions were the most common
types. However a significant number of cases had premalignant and malignant changes. The presence of the
associating factors acting alone or in combination were having a role in the existence of the lesions. The
premalignant potentials increase with age and the chronicity of the associating factors such as smoking and angular
chelitis were having a significant role in existence of the lesions. In addition, the results showed that the angular
hyperkeratotic lesions existed in the majority of the patients were bilateral in behavior.
Key words: Angular, Hyperkeratotic, Etiologic factors. (J Bagh Coll Dentistry 2012;24(2):51-55).
INTRODUCTION
Hyperkeratotic lesions “leukoplakias” are The investigators confirmed the property of
commonly seen on the oral mucous membrane. toluidine blue discoloration to verify clinically
Fortunately, most are benign and justify little suspicious lesions as neoplastic to delineate
clinical concern once a definitive diagnosis is margins of premalignant and malignant growth
made1. However, a small proportion of these and to detect unnoticed or satellite tumors7. The
lesions represent dysplastic, early malignant or high sensitivity of the test appears to offer a
neoplastic lesions of the surface epithelium. feasible diagnostic control and lesions that stain
Idiopathic leukoplakia is reserved for white with toluidine blue should be considered
lesions suspected of cancerous or precancerous carcinoma unless proven by biopsy.8-10
character when direct cause or specific benign When clinical hyperkeratotic lesions are studied
condition explains the abnormal appearance.2, 3 A microscopically they could be seen to embrace
variety of local irritations such as tobacco various histologic changes that shows only
products, hot and spicy foods, occlusal trauma, increase keratosis to invasive squamous cell
sharp prosthesis, presence of candida albicans, carcinoma. These differences cannot be identified
acting alone or in combination produce keratotic clinically so to establish a specific diagnosis the
lesions in certain individuals.1,4 Squamous cell lesion need to be examined microscopically.10,11
neoplasms of the oral cavity and leukoplakia Differential diagnosis of white lesions is based on
share many of the same etiologic factors.5 location, history, and other physical findings. The
Diagnosis of the dysplastic lesion and early distribution of leukoplakia lesions is of diagnostic
squamous cell carcinoma could not be determined value in the transmission to malignancy. The
based on the clinical findings only. tongue and the floor of the mouth are the most
Toluidine blue stain is a reliable clinical method common locations of malignant lesions; however
and proposed as a vital stain to disclose dysplasia the cheek and lips are the common sites of
and carcinoma in situ. The stain was used for the leukoplakia with dyskeratosis.12
detection of premalignant and malignant lesions A significant number of patients attending the oral
of the oral cavity.6 diagnosis clinic seeking dental treatment are
having white lesions, and may be unaware of it
since it is asymptomatic. In practice, the angle of
(1) Assistant professor, department of oral diagnosis. College of the mouth is exposed to fungal infections,
Dentistry, University of Baghdad.
Oral Diagnosis 51
occlusal trauma, smoking irritations, and is the lesions (36.6%). While the malignant neoplasms
common site of the lesion. were the 2nd in frequency (25.89%) having
The purpose of this study was to find out the mainly sqamous cell carcinoma (19.64%) which
incidence of the diagnosed hyperkeratotic lesions was highest than verrucous carcinoma (3.57%)
that are existed at the angle of the mouth, in and ca in situ (2.67%). Among the premalignant
addition to the frequency of the relation with the lesions which represent (21.42%) of the angular
etiologic or initiating factors. hyperkeratotic lesions, epithelial dysplasia had the
highest distribution (11.6%), followed by candidal
leukoplakia (7.14%) and verrucous leukoplakia
MATERIALS AND METHODS (2.6%).
A thorough clinical examination of the oral soft Benign growths which were mostly of viral origin
tissue was conducted for patients attended the oral represent the least in distribution (3.57%),
diagnosis clinic, college of dentistry, university of including papillpma, and verrucous vulgaris.
Baghdad in the period between 1997-2005. Lichen planus (dermatosis) was included when
Emphasis was done on angular hyperkeratotic the diagnosis was suspicious and should be
lesions. A total of 112 patients were selected for located at the angle of the mouth (fig.4). It was
this study. They were (62) males and (50) females not considered whether they were erosive and
with age ranges between (11-90) years. non-erosive and the result was (12.5%) of the
The information about systemic diseases, smoking total cases.
habits, presence of traumatic factors, and presence Table 2 summarized the relation between the
or absence of angular chelitis were collected and lesions in the males and females with the
registered in the case sheet. associating factors. The table was descriptive
The clinical method of investigation was done by rather than analytic, because number of cases of
applying toluidine blue stain protocol to the the specified lesions was small, so that the
mucosal lesion.7,10,13 The lesion was washed with associating factors did not give a conclusion about
water for few seconds for the removal of debris the effect of these factors on the specified lesion.
present, then rinsed with 1% acetic acid and However, the total numbers showed smoking
followed by swabbing with a piece of cotton habit (54.46%) was the highest in frequency.
socked with 1% toluidine blue stain. After Angular chelitis was also high (48.2%) because
application of the stain acetic acid was used again the number of patients having premalignant and
for discoloration. The lesions that picked up the malignant lesions showed significant number of
royal blue stain were considered malignant lesions associated with candidiasis. The effect of
neoplasm (fig. 3). While the lesions that have dental irritation and cheek biting (43.7%) and a
picked up few amount of the stain as dark spots history of presence of removable or fixed
inside a white lesion considered precancerous prosthesis (28.5%) showed a relation with benign
lesion (fig. 2). The entire positive and the hyperkeratosis in particular.
clinically suspicious negative reacted lesions were Presence of systemic diseases (oral and skin
biopsied and examined under the light microscope autoimmune diseases, diabetes, hypertension,
for the final diagnosis. The presence of dysplastic anemia, vitamin deficiency and drug allergy) as
changes within the epithelium regardless of the an associating factor of the lesions was seen in
severity was considered premalignant. The 35%. Alcohol consumption, regardless of the
suspicious lesions were selected and stained with amount used, was the least 0.05% in frequency.
PAS stain for the detection of candida albicans.
Presence of candidal hyphe within the lesions was
considered candidal leukoplakia. DISCUSSION
The data were collected and analyzed for the final The clinical manifestations of various white
results. lesions are the same. However, the histologic
appearance implicate different histologic
diagnosis varies in nature from benign to highly
RESULTS malignant potentials. Squamous cell carcinoma is
According to the clinical and histologic diagnosis, the most common malignant disease of the oral
the white lesions were classified into benign cavity and one of the few potentially fatal
lesions, premalignant lesions, benign growth, conditions the dentist is likely to initially identify.
malignant neoplasms, and lichen planus. Table 1 The site and distribution of the hyperkeratotic
shows the general classification of the lesions and lesions in the oral mucosa is considered an
the frequency distributions of the specific lesions important factor in the diagnosis and prognosis of
in their categories. Benign hyperkeratotic lesions the disease.1,3,12 About 71% of the hyperkeratotic
represent the most frequent among other angular lesions of the oral cavity are benign in nature.12
Oral Diagnosis 52
Angular benign hyperkeratotic lesions represent published that Smoker keratosis was oftenly
the majority of the cases diagnosed in this study benign and the development of dysplastic lesions
but the percentage (36.6%) shows less if apparently require several decades of exposure
compared with leukoplakias distributed in other because leukoplakia is unusual among young
sites of the oral mucosa. Locations and patients before 40 years and is more typical after
distributions of hyperkeratotic lesions in the oral the fifth dacade.12 This agree with our results that
mucosa indicate reliability to malignant premalignant lesions are existed in an elderly ages
transformation.11,14 The results showed neoplastic of the males and females.
lesions (carcinoma in situ, verrucous carcinoma, Angular mucosa is commonly subjected to
and squamous cell carcinoma) are in the second various irritation factors and the angle of the
place of occurrence at the angle of the mouth mouth is the common site exposed to trauma from
compared with other hyperkeratotic lesions at the occlusion of the canine and premolars and
same site. It was found that leukoplakia with removable or fixed prosthesis. The general
dyskeratosis occurs in the buccal mucosa as a first condition of the oral mucous membrane as
site in frequency compared with the other sites of influenced by both regional and systemic
the oral mucosa.15 Our findings revealed (21.42%) disorders is important in enhancing effectiveness
of the total hyperkeratotic lesions. Epithelial of the locally active factors. Systemic diseases
dysplasia is the majority diagnosed followed by such as nutritional deficiency, anemia, diabetes
candidal leukoplakia, and verrucous leukoplakia mellitus, lichen planus, xerostomia, and
respectively. autoimmuine diseases...etc are associated with
Lichen planus whether erosive and non-erosive atrophic changes in the oral mucous memberene
types were included when the location of the that predispose these patients to both leukoplakia
lesion was present strictly at the angle of the and oral carcinoma.19,20 In this study they were
mouth. In some cases the plaque type was commonly noticed associated with benign,
confusing with planer type leukoplakia in the premalignant, and malignant lesion as well as
clinical form, and the erosive types were similar with lichen planus.
to dysplastic lesions in their form of mixed red The presence of chronic infections at the angle of
and white lesion (fig. 4). the mouth due to candida albicans was seen
Benign neoplastic growths were seen at the angle associated with different specific lesions and the
of the mouth and diagnosed as papilloma and malignant lesions in particular. This was probably
verrucous vulgaris. They were viral in origin and more superimposing in nature than as initiative
diagnosed clinically and histologically. Verrucous factor. However, when hyperkeratosis at the angle
vulgaris was seen in young patients and one of the of the mouth associated with chronic irritation,
cases was an 11 year old child attended the clinic inflammation or infection due to angular chelitis,
having white verrucous lesion restricted at the and associating systemic diseases in adult and old
angle of the mouth (fig. 5). The lesion at the patients, biopsies were required to identify the
beginning gave the clinical manifestation of a dysplastic changes by using tolidine blue and
premalignant or even a malignant lesion, but there microscopic examination.
were papillomas located at the hands. The parent Alcohol consumption was the least associating
refused to take a biopsy so that the diagnosis was factor noticed in this study, the reason may be
based on the associated lesions of the hand and, in some patients deny this habit since socially and
addition the regression of the lesion after religiously is unaccepted in this country.
following up the case. A point worth mentioning during the clinical
The existence of the angular hyperkeratotic examination, it was noticed that the majority of
lesions in a wide range of age groups with no cases included in this study showed the angular
significant difference in both sexes made them of hyperkeratotic lesions were distributed in a
no diagnostic value in general. However, they bilateral behavior.
were useful in the diagnosis of the specified
lesions if correlated with the associated factors. REFERENCES
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Oral Diagnosis 53
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Oral Diagnosis 54
Table 1: The classification of the diagnoses of the angular hyperkeratotic lesions

Classification of the Number Age Age
Diagnosis Male Female
lesion (per%) range range
Benign epithelial 53.2 50.4
Benign lesions 41 (36.6%) 23 18
hyperkeratosis (22-80) (23-85)
50
60.4
(40-58)
Epithelial Dysplasia 13 (11.6%) 5 (45-75) 8
52.7
Candidal leukoplakia 8 (7.14%) 2 56 6
(26-90)
Premalignant lesions Verrucous leukoplakia 3 (2.67%) 1 (47-75) 2
61.5
73
(58-65)
63.1 53.73
Total 24 (21.42%) 8 16
(45-75) (26-90)
11
Verrucous vulgaris 2 (1.78%) 1 1 20
46
Papilloma 2 (1.78%) 2 0 0
(42-50)
Benign growth
28.5
Total 4 (3.57%) 3 1 20
(11-50)
58
(46-70) 1 60
Carcinoma in situ 3 (2.67%) 2
60.75 0 0
Verrucous carcinoma 4 (3.57%) 4
(48-73) 8 55
Malignant neoplasm Squamous cell carcinoma 22 (19.64) 14
58.4 (40-72)
(42-81)
59 57.5
Total 29 (25.89%) 20 9
(42-81) (40-75)
53.6 55.8
Dermatosis Lichen planus 14 (12.5%) 8 6
(24-85) (25-60)
62 53 50 40.5
Total 112 (100%)
(55.4%) (11-85) (44.6%) (20-90)
Table 2: The factors associated with angular hyperkeratotic lesions

Dental Systemic Angular
Diagnosis Gender number Smoker Alcohol Prosth.
Irritation Disease Chelitis
Benign F 18 6 0 8 7 7 4
hyperkeratosis M 23 18 3 11 9 6 5
F 8 5 0 5 4 3 5
Epith.dysplasia
M 5 4 1 3 3 2 3
Candidal F 6 4 0 3 2 2 5
leukoplakia M 2 2 0 2 1 0 4
Verrucous F 2 1 0 0 0 1 1
leukoplakia M 1 0 0 0 0 0 1
Carcinoma in F 1 1 0 1 0 0 1
situ M 2 1 0 1 0 0 1
Verrucous F 0 0 0 0 0 0 0
carcinoma M 4 3 0 3 0 1 1
Squamous cell F 8 4 0 2 0 6 7
carcinoma M 14 8 1 6 3 6 12
Verrrucous F 1 0 0 0 0 0 0
vulgaris M 1 0 0 0 0 0 0
F 0 0 0 0 0 0 0
Papilloma
M 2 0 0 1 0 0 0
F 6 1 0 1 2 4 1
Lichen planus
M 8 3 1 2 1 2 3
112 61 6 49 32 40 54
Total
(100%) (54.60%) (0.05%) (43.70%) (28.5%) (35.70%) (48.20%)
Oral Diagnosis 55
J Bagh College Dentistry Vol. 24(2), 2012 Pre-implant computed
Pre-implant computed tomography and insertion torque

measurement in qualitative determination of trabecular
bone density
Mahmood J. Hamzah, B.D.S. (1)
Jamal A. Al-Taei, B.D.S., M.Sc. (2)
ABSTRACT
Background: Bone density is a very important factor in the successful plan of implant treatment. The aim of the study
is to evaluate the trabecular bone density of potential dental implant sites in different region of the jawbone by using
Computerized Tomography (CT) , and the relationship between bone density and insertion torque.
Materials and method: In this clinical study 64 patients were treated with 120 Xive FRIADENT DENTPLY system implants.
The implant recipient sites were divided in two groups according to gender; 60 in males and 60 in females and each
group was divided into subgroups according jaw (maxilla and mandible) and region (anterior and posterior). The
bone density of each implant recipient site was recorded in Hounsfield units (HU) using CT. The maximum insertion
torque (Ncm) values were recorded with torque controlling motor.
Results: There was a significant correlation between bone density and insertion torque in males (r=0. 983, p <0.001)
and females (r=0.955, p <0.001).The trabecular bone density values were (682±98 HU, 481±104 HU, 413±92 HU, and
263±67 HU) values in the anterior mandible, posterior mandible, anterior maxilla, and posterior maxilla, respectively.
Trabecular bone density was higher in males in comparison to females and the bone quality was higher for the
mandible than for the maxilla, and higher for the anterior region than for the posterior region of these bones. In
females there is no significant difference in bone density (p<0.05) between the posterior mandible and anterior
maxilla and between males and females at posterior maxilla (p<0.001).
Conclusion: Trabecular bone density is a key determinant for clinical success; CT is a useful tool for assessing the
bone density
Key words: dental implants, computerized tomography, insertion torque, bone density. (J Bagh Coll Dentistry
2012;24(2):56-61).
INTRODUCTION Some researchers have reported that CT is a

Dental implants have become a popular good tool for evaluating the bone density at
alternative in oral rehabilitation in the past two potential dental implant sites (2, 4, 7, 9–17). The
decades; even though the clinical outcome of an quality of bone in the jaw has been studied
implant is influenced by many factors, including previously (4, 9, 11) but not in the Asian population.
the implant body, skill of the surgeon, and the oral The aim of this study was therefore to evaluate
environment. The key factor for success is the the trabecular bone density of potential dental
primary stability at implant placement. The implant sites in different regions of the Iraq
quality of the alveolar bone is the most important jawbone using CT images.
factor for achieving good primary stability (1, 2).
There are many different definitions of bone MATERIALS AND METHODS
quality, but it is generally presented as the sum of A total of 73 Iraqi patients aged 23-45 years
all of the characteristics of bone that influence its old, males and females, attend our private clinic in
resistance to fracture (3). The term ‘bone quality’ Holy Karbala’ City. The study extended from
was introduced to refer to the different bone November 2010 to July 2011. Out of these73
density types. In the field of dentistry, Lekholm patients full or partial edentulous, 64 subjects (31
and Zarb classified jawbone density into four males & 33 females) were included in this study.
types based on the amounts of cortical bone The implant recipient sites (120) were divided in
versus trabecular bone evident on pantograph film two groups according to gender; 60 implant
(4, 5) recipient sites in males and 60 implant recipient
. Computed tomography (CT) is one of the
most useful medical imaging techniques for sites in females and each group was divided into
assessing not only the structure of the body tissue, subgroups according to the jaws (maxilla and
but also its density. Theoretically, the bone mandible) and regions (anterior and posterior).15
density, which is measured in Hounsfield units in anterior maxilla, 15 in posterior maxilla, 15 in
(HU), is directly related to the tissue attenuation anterior mandible and 15 in posterior mandible.
coefficient (6–8). Selective criteria of study sample:
The patients were selected according to
(1) Master Student, College of Dentistry, University of Baghdad. medical and potential implant site evaluation as
(2) Assistant Professor, Department Oral Radiology, College of follows:
Oral Diagnosis 56
a- Medical evaluation: (anterior mandible, posterior mandible,

Sample individual should have no history of anterior maxilla and posterior maxilla.
any systemic disease that might affect bone E. P value of less than the 0.05 level
metabolism like (P<0.05) of significance was considered
1- Diabetes Mellitus. statistically significant.
2- Tuberculosis.
3- Cushing's syndrome.
4- Hyperparathyroidism. RESULTS
5- Generalized osteoporosis. 1-Relation between the average bone density
6- Heavy smokers. (BD) and the maximum insertion torque
7- In patients with a long period of time (torque) in males and females
having steroid therapy. The BD and torque in males (541±229 HU, 33±8
8- Radiotherapy (60GY) in patients with N cm) were higher than females (378±123 HU, 27
head and neck cancers (18-20). ±4 Ncm) and highly significant difference
b- Potential implant site: between males and females as shown in table (1).
1-The Region of interest is larger than There is significant correlation between average
9.6mm². bone density and maximum insertion torque in
2- Diameter greater than 3.5mm. males and females table (2).
3- longer than 6 mm in the alveolar 2- Relation between the maxilla and mandible
trabecular bone. in average bone density (BD) and the
Material maximum insertion torque.
X-ray machine BD and the torque were significantly higher in the
A spiral Computed Tomography (CT) mandibles (581±202 HU, 35±4 N cm) in
machine (GE LighSpeed VCT, 64 slice, USA) (in comparison to the maxillae (338±80 HU, 26±3 N
IRAQI MEDICAL CENTER- Holy KERBALA cm) and highly significant difference between
City) which will be calibrated daily according to mandibles and maxillae. There is significant
the manufacturer's instruction. correlation between average bone density and the
A range of 5 cm will be covered in 9.9 seconds, maximum insertion torque in maxillae and
Kv 140, mA 334, rot 0.50 second, slice width 1.25 mandibles table (3).
mm and pixel size 512x512. There is significant correlation between BD and
Dental implant: the torque in maxillae and mandibles table (4).
The dental implants used in this study are 3- Relation between the maxilla and mandible
XiVE Dentsply Friadent system. XiVE implants in average bone density and the maximum
are available in diameter D 3.0- D 5.5 mm and in insertion torque at each region in males and
lengths of 8-18 mm. females
Torque controlling motor: In males
High torque micro motor (FRios unit Si Higher BD and the torque had been found in the
DENTSPLY FRIADENT), (W&H; Austeria) and anterior mandible followed by the posterior
contra-angle speed reduction (20:1) hand piece mandible, then anterior maxilla and the last
(W&H; Austria). posterior maxilla. For the differences among the
Statistical data analysis: four regions in males figures (1) & (2); ANOVA
The data were processed and analyzed using test show a high significant difference in the BD
SPSS (Statistical Package for Social Sciences) and the torque in regions (p< 0.01). The LSD test
version 19 computer software. also shows a high significant difference in the BD
A. Use t-test to compare the mean of two and the torque in each region in relation to others.
groups (males and females). In females
B. Pearson correlation to test the linear Higher BD and the torque had been found in
relationship between each two variables anterior mandible followed by the posterior
(average bone density and insertion mandible, then anterior maxilla, and the last
torque). posterior maxilla. For the differences among the
C. ANOVA test to test for differences in four regions in females' figures (1) & (2).
means of more than two groups. When ANOVA test shows a highly significant
the result proves significant this would be difference in the BD and the torque in regions.
followed by LSD test. The LSD test also shows a no significant
D. LSD (Least significant difference test) to difference in the BD and the torque between the
check which two groups are different posterior mandible and the anterior maxilla
(p<0.05).
Oral Diagnosis 57
including the measurement of the bone mineral

contents in the jaws and forearms have already
indicated that, when compared to the males, lower
bone mineral densities in females have been
found throughout adult life (33). However, this
finding is in agreement with (28,34).
In the present study, the difference in the
average bone density of the implant recipient sites
between the mandibles (581±202 HU) and the
Figure 1: Box chart average of bone density maxillae (338±80 HU) was statistically of high
in different regions in males and females significance for all patients, this finding is in
agreement with (35), who reported that the
difference in the average bone density of the
implant sites between the mandibles (828 ± 245
HU) and the maxillae (582 ±192 HU) was
statistically significant for all patients.
The mean bone densities recorded in this study
are lower than those reported by (35, 36) table (1),
which might be due to the previous measurements
including the trabecular bone and the outer
cortical shell. The density of cortical bone is
Figure 2: Box chart maximum insertion significantly higher than that of trabecular bone.
torques in different regions in males and However, we observed higher mean bone
females. densities than did (37), which might be due to the
use of different types of software. In the two
studies de-Oliveira et al indicated that this could
DISCUSSION yield different bone density values from the same
Bone density CT images.
Many studies have demonstrated that the In addition, the ranges of the mean bone
survival rate of an implant is significantly affected density in the present study are broadly consistent
by the host bone quality (21-25), and hence a with those of (38, 39) table (5). The differences
preoperative evaluation of the bone condition is between the present study and the previous
essential for assisting the dentist when planning studies come from the distribution of implant
implant therapy. recipient sites. Because the effect of number of
The use of CT, which is more objective and implant sites in region was neglected in previous
reliable for the assessment of the bone density of studies.
the patients requiring implant therapy, was As the bone is reduced in volume to C shape
introduced (26). minus height (C-h), especially in the anterior
In this study, alveolar trabecular bone density mandible. The C-h mandible often exhibits an
was evaluated in different regions of the jawbone increase in torsion or flexure in the anterior
from spiral CT images. segment between the mental foramens during
It is not passable to make a direct comparison function. This increased strain causes the bone to
between the present study and previous studies increase in density (40). In this study and all
because many previous studies on the bone previous studies was found that most density was
density from CT included cadaver specimens (29- in the anterior mandible (35-39).
32)
. The bone density recorded in the present
In the present study, the male patients had a study were (682±98 HU, 481±104 HU, 413±92
higher average bone density value at the implant HU, and 263±67 HU) values in the anterior
sites than that in female patients (the mean of mandible, followed by the posterior mandible,
average bone density of all implant recipient sites anterior maxilla, and posterior maxilla,
was (541±229 HU in males; while in females respectively.
378±123 HU), there was a statistically higher Shapurian et al. (38) found that the mean bone
significant difference in the average bone density density was lower in the posterior mandible than
of implant sites between males and females. in the posterior maxilla (in contrast to the results
This finding may be explained with the of the present study). These discrepancies might
hormonal peculiarities in females and generally have resulted from the distribution of implant
higher bone mass in males. Previous studies recipient sites, because a relatively high number
Oral Diagnosis 58
of their implant recipient sites were in the with dental quantitative CT prior to dental implant
posterior mandible which has the lowest bone placement in cadaver mandibles: pilot study.
Radiology 2002; 224:247–52.
density values.
8. Chen WP, Hsu JT and Chang CH. Determination of
In this study, it has been observed that the Young’s modulus of cortical bone directly from
average bone density value of the implant sites in computed tomography: a rabbit model J Chin Inst
the anterior regions of jaws was higher than that Eng 2003; 22:121–8.
in the posterior regions (anterior mandible– 9. de Oliveira RC, Leles CR, Normanha LM, Lindh C. and
posterior mandible; anterior maxilla–posterior Ribeiro- Rotta RF. Assessments of trabecular bone
density at implant sites on CT images. Oral Surg Oral
maxilla).
Med Oral Pathol Oral Radiol Endod 2008; 105:231–
This finding is in conformity with those 8.
reported by (35-39). 10. Norton MR and Gamble C. Bone classification: an
In the present study there is no significant objective scale of bone density using the
difference in the mean bone density between the computerized tomography scan. Clin Oral Implants
anterior maxilla and the posterior mandible in Res 2001; 12:79–84.
11. Turkyilmaz I, Tozum TF and Tumer C. Bone density
females, while in males there was a statistically
assessments of oral implant sites using computerized
significant between the posterior mandible and the tomography. J Oral Rehabil 2007; 34:267–72.
anterior maxilla. This finding is partially in 12. Iwashita Y. Basic study of the measurement of bone
agreement with (35); stated that there are mineral content of cortical and cancellous bone of the
differences in the average bone density of the mandible by computed tomography. Dentomaxillofac
implant sites that was not statistically significant Radiol 2000; 29:209–15.
13. Loubele M, Maes F, Schutyser F, Marchal G, Jacobs R
between the posterior mandible and the anterior
and Suetens P. Assessment of bone segmentation
maxilla. quality of cone-beam CT versus multislice spiral CT:
Insertion torque a pilot study. Oral Surg Oral Med Oral Pathol Oral
The insertion torque is the latest value seen on Radiol Endod 2006; 102:225–34.
the screen was recorded. Starting from 20Ncm, 14. Shahlaie M, Gantes B, Schulz E, Riggs M and Crigger
the insertion torque was increased in steps of M. Bone density assessments of dental implant sites:
1. Quantitative computed tomography. Int J Oral
5Ncm, when the rotation stopped due to friction
Maxillofac Implants 2003; 18:224–31.
before the implant was fully inserted. Only a 15. BouSerhal C, Jacobs R, Quirynen M and van
limited amount of torque could be applied in order Steenberghe D. Imaging technique selection for the
to avoid mechanical overload of the equipment on preoperative planning of oral implants: a review of
bone tissue. the literature. Clin Implant Dent Relat Res 2002;
Statistically significant strong correlations 4:156–72.
16. Turkyilmaz I, Tozum TF, Tumer C and Ozbek EN.
between bone density and insertion torque were
Assessment of correlation between computerized
found at implant placement. This fact concurs tomography values of the bone, and maximum torque
with the previous studies (36, 39, 41, 42). and resonance frequency values at dental implant
placement. J Oral Rehabil2006; 33:881–8.
17. Turkyilmaz I and McGlumphy EA. Is there a lower
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26. Schwarz M. S, Rothman SLG, Rhodes M L & Chafetz 35. Turkyilmaz I, Tumer C, Ozbek EN & TÖzüm TF.
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Implants1987; 2: 137–41. implants. J Clin periodontal 2007b; 34: 716-22.
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28. Ikumi N & Tsutsumi S. Assessment of correlation Ribeiro-Rotta RF . Assessments of trabecular bone
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Table 1: Comparison of BD and torque in males and females at level (p <0.01).

Males and
t Sig.
females
BD 4.840 0.0005
Torque 4.364 0.0005
Table 2: Correlation between average bone density and maximum insertion torque in males and
females at the (p<0.01) level.
Gender
Males Females
Torque Torque
Pearson correlation 0.983 0.955
BD
Sig. 0.0005 0.0005
Table 3: Comparison of BD and torque in mandibles and maxillae at level (p <0.01).

t-test for Equality of Means
Maxilla & Mandible
t Sig.
BD 8.62 0.0005
torque 8.01 0.0005
Oral Diagnosis 60
Table 4: Correlation between BD and torque in Maxilla & Mandible at the (p<0.01) level.
Maxilla & Mandible torque
BD Pearson correlation 0.938
Sig. 0.0005
N. 120
Table 5: Reference that shows bone densities in different regions of the jawbone [expressed in
Hounsfield units (HU); numbers within parentheses are sample sizes]
Region
Anterior Posterior Anterior Posterior
mandible mandible maxilla maxilla
Shapurian et al.
559±208(42) 321±1132(78)517±177(45) 333±119(54)
(2006)
Turkyilmaz et al.
945±207(58) 674±227(28) 716±190(28) 455±122(21)
( 2007a)
Turkyilmaz&
846±234(100) 526±107(60) 591±176(70) 403±95(70)
Mcglumphy (2008)
de-Oliveira et al.
383±243(6) 306±187(28) 370±176(6) 255±184(29)
(2008)
Fus et al. (2010) 530±161(15) 359±150(55) 516±132(47) 332±136(37)
This study 682±98(30) 481±104(30) 413±92(30) 263±67(30)
Oral Diagnosis 61
J Bagh College Dentistry Vol. 24(2), 2012 Evaluation of oral health
Evaluation of oral health status in a sample of autistic

male children
Mayyadah H. Rashid, B.D.S., M.Sc.(1)
Raja H. Al-Jubouri, B.D.S., M.Sc., Ph.D. (2)
ABSTRACT
Background: Autism is a severe neurodevelopmental disorder, presents in early childhood, characterized by severe
impairments in socialization, communication and behavior. Autism is considered a multi-factorial disorder that is
influenced by genetic, environmental, and immunological factors with oxidative stress as a mechanism linking these
factors. Assessment of any oral manifestations has to be discovered, evaluated and measured in autistics to be used
as a potential diagnostic.
Materials and methods: Oral health status:(DMFT) for permanent teeth, (dmft)for deciduous teeth and gingival
indices were estimated for 58 individuals aged (2-13) years, twenty nine of them were autistics and twenty nine were
sex and age matched healthy controls.
Results: The results of this study showed that Iraqi autistic children sample was more likely to be caries-free compared
with healthy sample.
Conclusion: Children with autism spectrum disorder (ASD) were more likely to be caries-free, had lower DMFT\ dmft
and GI scores than did their unaffected peer and can be used in autism spectrum disorder prediction to a limited
extent.
Key words: Autism spectrum disorder; Oral health status. (J Bagh Coll Dentistry 2012;24(2):62-65).
INTRODUCTION
Autism spectrum disorders (ASDs) are prevalent Given the well-established fact that mercury (Hg)
neurodevelopmental disorders that affect an is known to significantly increase oxidative stress
estimated 6 per 1,000; with male to female ratio and that fetuses and infants are routinely exposed
averages 4.3:1, which means that boys are at to Hg from environmental sources (fish, dental
higher risk for ASD than girls (1).Characterized by amalgams, etc.), investigators have described that
severe impairments in socialization, communicat- many ASDs may result from a combination
ion and behavior. Children diagnosed with an ofgenetic/biochemical susceptibility, specifically
ASD may display a range of problem behaviors areduced ability to excrete Hg, and exposure to
such as hyperactivity, poor attention, aggression Hg at critical developmental periods.Further, it
and self-injury. In addition, to unusual responds to was reported that Hg can cause immune, sensory,
sensory stimuli such as hypersensitivities to light neurological, motor, and behavioraldysfunctions
or certain sounds, colors, smells or touch and have similar to traits defining/associated with ASDs,
a high threshold for pain(2).Finally, common co- and that these similarities extend to
morbidity conditions often associated with ASDs neuroanatomy, neurotransmitters, and
include gastrointestinal and autoimmune disease biochemistry. Also, it was reported when
(3)
. reviewing the molecular mechanisms of Hg
Investigators suggested that ASDs may result intoxication that it can induce death,
from an interaction between genetic, disorganization and/or damage to selected neurons
environmental and immunological factors, with in the brain similar to that seen in recent ASD
oxidative stress as a mechanism linking these risk brain pathology studies, and this alteration may
factors (4). likely produce the symptoms by which ASDs are
Oral health and dental needs of children diagnosed(6).
withautism have been evaluated by very few
investigators. The studies conducted on this topic MATERIALS AND METHODS
reported nostatistically significant differences in Sixtyindividuals from Central Pediatric Teaching
the prevalence of caries, fillings, gingivitis and Hospital in Al-Iskanwere enrolled in this study.
degree of oral hygiene in comparison with non- They were categorized into two groups:
autistic individuals8, and even a lower incidence Autistic group: Composed of 31 children (29
of caries in some of the reports(5). males and 2 females) who were diagnosed as
autistic children, their ages range between 2-13
years. Because the female sample very small, it
(1) M.Sc. Oral medicine, Specialist in Ministry of Health. was excluded from the current study.
(2) Professor, Department of Oral Diagnosis , College of
Dentistry, Baghdad University
Healthy control group: Composed of 29 age and
gender matched male children.
Oral Diagnosis 62
All individuals were evaluated by full medical According to criteria, 96,6% of autistic
history and clinical examination to exclude any children had mild gingivitis with mean value
other systemic disease that may affect the (0.55 ± 0.35) obviously lower in comparison to
parameters examined in this study. Oral and healthy controls (0.75 ± 0.48), but the difference
periodontal examination was done for each failed to reach the level of statistical significance
individual and any child with symptoms and signs (p=0.08).
of any active oral inflammation and advanced Tables2 and 3 summarize an assessment of
periodontitis were excluded. DMFT, dmft and GI scores among the study
All parents were supplied with informed consent subjects with ASD in comparison to the
and the purposes of the study wereexplained to controls.Table 4 showing the tested variables
them.All the children subjected to extra-oral ordered according to their significance in
examination for any scars or trauma to the head, separating between autistics and healthy controls
neck, hands and fingers; taking medical, family (ROC test).
history and previous dental history.Intra-Oral
assessment of caries experience through the DISCUSSION
application of decayed, missing and filled teeth Boys are at higher risk for ASD than girls and this
Index (DMFT) and (dmft) for permanent and agreed with all other studies around the world (1,
primary teeth respectively; and assessment of 3)
. As part of the multiple unknown develop-
gingival health status through gingival index (7). mental abnormalities, children diagnosed with
All data were statistically analyzed using SPSS autism practice self-injurious behavior (SIB) at
version 13 (Statistical Package for Social some stage in their lives. In the present study
Sciences). Non-normally distributed quantitative results of the extra oral assessment, types of
variables (DMFT\dmf score) are described by habits, trauma and injuries revealed that out of the
median and interquartile range. The remaining 29 examined children, only 2 (6.9 %) practice this
quantitative variables (age and gingival index) behavior, and this result was in good agreement
were normally distributed and thus conveniently with many other studies (8,9). Heritability
described by mean ± standard deviation. contributes about 90% of the risk of a child
Correlation assessment was performed using the developing autism,and this support the findings in
Spearman correlation analysis. The ROC analysis the present study in which 21 (72.4 %) of autistic
was used to rank the quantitative parameters from children have a positive family history of
those with highest difference between Autism neuropsychiatric illness like schizophrenia,
cases and healthy controls to lowest difference. Alzheimer’sdisease, mental disorder and
This is done by ranking the ROC area of different depression(10).
parameters. Statistical significance was defined as In the present study 28 children (96.6%) had
p< 0.05. never visited dental clinic or received dental
treatment and follow upand this could be
RESULTS explained by the fact that people with ASD
The mean age for autistic children was about incapable of cooperating in the dentalsetting
5.9±3.4 years. Autistics and their controls showed owing to their impaired social interaction and
homogeneity and there were no significant communicationskills. In addition to cognitive
difference between the two groups. dysfunction, aggression and other associated
Extra-Oral Examination: out of 29 autistics only 2 psychiatric symptoms may impede the provision
(6.9%) showed signs of trauma due to self-injury of dental care. This result was in good agreement
habit. Parents' responses to the questionnaire with many studies (11-14).
regarding dental visits indicated that 28 (96.6%) The current study revealed that caries severity
of autistic children never visited dental clinic and (but failed to reach statistical significant level) in
had a negative history of treatment and follow up autistics were lower than in unaffected children
as shown in table (1). with autism, because of their ritualistic
Intra – Oral Examination: The caries severity of behaviorwhich characterized by unvarying pattern
children in the ASD group was statistically of daily activities, such as an unchanging menu so
significantlower than that in the unaffected group they are moreregular in their behavior at meals
for dmft(p = 0.013) but insignificant for DMFT (p than are unaffected children.Therefore, a lower
= 0.73). Regarding caries prevalence, a total of 15 frequency of snacking between meals and
(51.7%) childrenin the ASD group had a positive lowerintake of carbohydrates could have
caries free history (DMFTand dmft=0), compared contributed to the lowercaries rate observed and
with9 (31%) children in healthy control group. this finding agreed with several studies (9,
15)
.While disagreed with others who reported
Oral Diagnosis 63
higher scores in autistic groups (5, 16). Caries REFERENCES

prevalence lower in autistic children participating 1. Newschaffer CJ, Croen LA, Daniels J et al. the
in the present study and this result were in good epidemiology of autism spectrum disorders. Annu
agreement with many previous studies (9, 5). Rev Public Health 2007; 28:235–58.
Gingival status of the autistic children in the 2. Austin D. An epidemiological analysis of the ‘autism
present study showed that (96,6%) of the children as mercury poisoning’ hypothesis. International
Journal of Risk and Safety in Medicine 2008; 20:135-
had generalized mild gingivitis, which it was in 42.
good agreement with many previous studies (5,16). 3. Geier, Kern, Geier. A prospective study of oxidative
While Ozdemir-Ozenenand Sandalli, 2007 (17), in stress biomarkers in autistic disorders. Electronic J
their study reported that the gingival index records Applied Psychology 2009; 5(1): 2-10.
of the children with autism was found to be 4. James SJ, Melnyk S, Jernigan S, Cleves MA, Halsted
significantly higher than the healthy children. CH, Wong DH, Cutler P, Bock K, Boris M,
Bradstreet JJ, Bake SM, Gaylor DW. Metabolic
All these findings could be related to many endophenotype and related genotypes are associated
reasons such as the irregular brushing habits with oxidative stress inchildren with autism.
because of the difficulties the trainers and the American Journal of Medical Genetics, Part B:
parents encountered when they brushed the Neuropsychiatric Genetics 2006; 141: 947-56.
children's teeth. It could also be due to lack of the 5. Ebtissam Zakaria Murshid. Oral health status, dental
necessary manual dexterity of autistic children needs, habits and behavioral attitude towards dental
treatment of a group of autistic children in Riyadh,
during brushing by themselves, which made their Saudi Arabia. Saudi Dent J 2005; 17: 3.
tooth brushing inefficient. Furthermore, the 6. Geier DA, King PG, Sykes LK, & Geier MR. A
findings of this study reflect poor dental comprehensive review of mercury provoked autism.
awareness, a lack of dental education and Indian J Medical Res 2008; 128: 383-411.
deficiency in receiving oral hygiene instructions 7. Silness J, Löe H. Periodontal disease in pregnancy II
from dental staff. Care-givers need to know the correlation between oral hygiene and periodontal
condition. ACTA OdontolScand 1963; 22:121-135.
different techniques and materials of tooth 8. Dominick KC, Davis NO, Lainhart J, Tager-Flusberg
brushing with emphasis on behavior modification H, Folstein S. Atypical behaviors in children with
to control the behavior of the children and regular autism and children with a history of language
dental visits. impairment. Res DevDisabil 2007; 28(2):145–62.
In the present study, aim was directed to assess 9. Cheen Y, Loo, Richard M, Graham, Christopher V,
and measure any oral manifestations associated Hughes. The Caries Experience and Behavior of
Dental Patients with Autism Spectrum Disorder. J
with ASD, which could be used for the early Am Dent Assoc 2008; 139: 11: 1518-24.
diagnosis and intervention with autism. Although 10. Freitag CM. The genetics of autistic disorders and its
there is no known cure, but early behavioral or clinical relevance: a review of the literature. Mol
cognitive intervention can help autistic children Psychiatry 2007; 12(1):2–22.
gain self-care, social, and communication skills. 11. Barbaresi WJ, Katusic SK, Voigt RG. Autism: a
Up to our knowledge, this study is the first of its review of the state of the science for pediatric
primary health care clinicians. Arch Pediatr Adolesc
kind that evaluate the usefulness of oral health Med 2006; 160(11):1167–75.
status as diagnostic aid through measuring the 12. Friedlander AH, Yagiela JA, Paterno VI, Mahler ME.
DMFT, dmft and GI under condition of stress due The neuropathology, medical management and dental
to autism in a sample of Iraqi autistics. implications of autism. JADA 2006; 137(11):1517–
The ROC test results of this study revealedthat the 27.
areas under ROC curve for DMFT (0.521) was 13. Marshall J, Sheller B, Williams BJ, Mancl L, Cowan
C. Cooperation predictors for dental patients with
not significantly different from 0.5 value of an autism. Pediatr Dent 2007; 29 (5): 369–76.
equivocal test (p = 0.79).And for dmft was 14. Pilebro C, Backman B. Teaching oral hygiene to
significantly higher (0.669) from 0.5 value of an children with autism. Int J Paediatr Dent 2005; 15
equivocal test (p = 0.027). ), while the areas under (1):1–9.
ROC curve for GI was higher (0.669) from 0.5 15. Lam KSL, Aman MG. The Repetitive Behavior
value of an equivocal test, but statistically Scale-Revised: independent validation in individuals
with autism spectrum disorders. J Autism Dev Disord
insignificant (p = 0.11).So dmft ranked number 2007; 37(5):855–66.
onefollowed by GI then DMFT as ranked third in 16. De Mattei R, Cuvo A, Maurizio S. Oral assessment of
order of importance in this study as shown in table children with an autism spectrum disorder. Journal of
(3). Dental Hygiene 2007; 81: 3.
17. ÖzdemirÖzenen D, Çıldır ŞK, Sandallı N. The oral
health status of children with visual impairment. 12th
Congress of the BaSS, İstanbul, Türkiye; 2007.P.12-
14.
Oral Diagnosis 64
Table 1: Extra-oral examination and case history of autistics

No. of +ve No. of -ve
Conditions % %
cases cases
self-injurious behavior and signs of trauma 2 6.9 % 27 93.1%
Family history of neuropsychiatric disorders 21 72.4 % 8 27.6%
Rubella Vaccine 29 100 % 0 0%
previous dental experience 1 3.4 % 28 96.6%
Table 2:Mean±SD for tested parameters

Markers Cases Controls p
Gingival index 0.55 ± 0.35 0.75±0.48 0.08 [NS]
Table 3: Median level for selected parameters

Markers Cases Controls p
DMF 0 0 0.73[NS]
dmf 0 1 0.013
Table 4: ROC analysis of testedparameters

parameters Area under the curve P
dmf 0.669 0.027
Gingival index 0.622 0.11[NS]
DMF 0.521 0.79[NS]
Oral Diagnosis 65
J Bagh College Dentistry Vol. 24(2), 2012 Ovulation detection
Ovulation detection through salivary levels of sialic acid

and glycosaminoglycans
Rand M. Al-khafagy, B.D.S., M.Sc. (1)
Sahar H. Al-Ani, B.D.S., M.Sc. (2)
Ali Y.Majid, M.B.ch.B., M.Sc., F.I.C.M.S. (3)
ABSTRACT
Background: One in ten couples of reproductive age encounter some level of infertility. Identification of the period
of ovulation in humans is critical in the treatment of infertility. Success in in vitro fertilization and embryo transfer has
been associated with the exact time of ovulation. Saliva is a unique diagnostic fluid, the composition of which
immediately reflects the sympathetic nervous system, parasympathetic nervous system, hypothalamic- pitutary-
adrenal axis and immune system response to stress. The study aims at evaluating the changes in salivary sialic acid
and Glycosaminoglycans in the regular menstrual cycle. Thus, the presence of these carbohydrates in the ovulatory
saliva makes the possibility to develop a biomarker for the detection of ovulation by noninvasive methods.
Subjects, materials and methods: Randomly, seventy five volunteer females were recruited and divided into 5
groups; each contains 15 subjects as follow: Nine years old females and postmenopausal females as control groups,
pre-ovulatory period, ovulatory period and post-ovulatory period females as experimental groups. Each female, of
the experimental groups, underwent sonographic examination to estimate her period regarding ovulation.
Unstimulated whole saliva was collected using the spitting method. Colorimetric procedure was used for total sialic
acid determination and for Glycosaminoglycans quantitative determination, the method of ELISA was used.
Results: The concentration of sialic acid was significantly decreased in saliva of females in the ovulatory phase of the
menstrual cycle; whereas, a significant increase in salivary sialic acid concentration was in the post-ovulatory phase.
Glycosaminoglycan concentration showed a gradual increase from the pre-ovulatory phase then ovulatory to reach
its maximum in the post-ovulatory phase with a significant difference between the pre-ovulatory and post-ovulatory
phases. A significant correlation was not found between sialic acid and Glycosaminoglycans in different study
groups.
Conclusions: On the basis of the results arrived at, the study concluded that there are remarkable cyclic variations in
sialic acid and glycosaminoglycans during the menstrual cycle but in conclusion, glycosaminoglycans and sialic
acid salivary levels cannot be used for the precise prediction of ovulation.
Keywords: Ovulation, saliva, sialic acid, glycosaminoglycans. (J Bagh Coll Dentistry 2012;24(2):66-69).
INTRODUCTION
The cyclic physiologic changes are mainly Carbohydrates are the major diet for mammalian
brought about by the ovarian hormones estrogen species. The nature of the feeding habit would
and progesterone, the levels of which show have a major impact on the excretion of
variation during the menstrual cycle. biomolecules. This may be the reason for a
Identification of the period of ovulation in humans considerable release of carbohydrates in the saliva
(3,4)
is critical in the treatment of infertility. Success in . Most of the salivary proteins are
in vitro fertilization and embryo transfer has been glycoproteins. Sialic acid (SA) is one of the
associated with the exact time of ovulation. In the terminal sugars of salivary glycoproteins. It is an
recent years, attention has been paid to the important structural component of salivary
noninvasive method in ovulation detection (1). glycoproteins, enhancing bacterial aggregation as
Saliva is a unique diagnostic fluid, the well as participating in the formation of the
composition of which immediately reflects the acquired pellicle and dental plaque (5). A previous
sympathetic nervous system, parasympathetic study suggests that bovine submaxillary mucin
nervous system, hypothalamic-pituitary-adrenal has hydroxyl radical scavenging ability and the
axis and immune system response to stress (2). SA in mucin is an essential moiety to scavenge
Recent reports shows that the saliva is a very good hydroxyl radicals and mucin synthesis is induced
source of both hormones and biochemicals and by oxidative stress (6).
that their levels change in accordance with the Proteoglycans are macromolecular components of
menstrual cycle (1). the extracellular matrix that play various roles in
normal cell physiology and in pathologic states (7).
Modulation of proteoglycan turnover by follicular
stimulating hormone (FSH) and luteinizing
(1) Ministry of Health, Iraq. hormone (LH) is mostly related to the ovulatory
(2) Assistant Professor, department of Oral Medicine, College of
Dentistry, University of Baghdad. process (8). A recent study suggests changes in
(3) Chemical Pathology salivary glycosaminoglycan (GAGs) and sialic
Oral Diagnosis 66
acid that are parallel to the normal increases in menstrual cycle. In the experimental groups, the
serum estrogen levels that occur in normal lowest salivary GAGs level was in the pre-
menstrual cycle (1). ovulatory phase compared to control groups
followed by a gradual increase in the ovulatory
MATERIALS AND MEHODS phase and the peak level was in the post-ovulatory
This is a cross-sectional study in which seventy phase as shown in fig 2. A statistically significant
five volunteer females were recruited and divided difference was found between the pre-ovulatory
into 5 groups; each contains 15 subjects as follow: phase GAGs level and the post- ovulatory phase
Group A: Eight to nine years old females level (p=0.013). Also the levels showed a high
represent the pre-pubertal period. (Control group) significant difference between the pre-ovulatory
Group B: Reproductive age females in the pre- phase and the postmenopausal group (p=0.0001).
ovulatory period. (Experimental group) No significant differences were found among the
Group C: Reproductive age females in the other groups.
ovulatory period. (Experimental group)
Group D: Reproductive age females in the post- DISCUSSION
ovulatory period. (Experimental group) Sialic acid
Group E: Postmenopausal females (10-20 years According to this study, SA level in old age group
after menopause). (Control group) (above 45) were almost similar to that of children
Each female, of the experimental groups, (8-9 years old) and are also not far away from its
underwent sonographic examination first to level in young adult except for its level in the
estimate her period regarding ovulation. post-ovulatory phase. This means that salivary
Unstimulated whole saliva was collected using the sialic acid concentrations are almost constant and
spitting method (9) for 10 minutes. For total sialic not related to age. This is in accordance with
acid determination, the colorimetric procedure another study that found similar SA concentration
was used and the optical density was read at 549 from birth to adulthood (10). Meanwhile, this result
nm (540-555nm) and the concentration of sialic is a disagreement with two other studies (11, 12) that
acid was calculated according to standard curve. stated that SA in human unstimulated saliva was
For Glycosaminoglycans quantitative affected by age with a trend toward reduction in
determination, the method of ELISA was used, SA concentration with age. The result of this
the absorbance (OD value) was determined at study is also a disagreement with Narhi et al. (13)
wave length 540nm and the concentration of GAG who stated that the concentration of SA and
was calculated according to standard curve. salivary peroxidase was highest in the oldest age
group.
RESULTS As mentioned, the results of the present study
Saliva sialic acid and GAGs concentrations were revealed low concentration of SA in the pre-
almost constant in different age groups and not ovulatory phase saliva; this is in accordance with
related to age. two old studies that had observed decreased
In the experimental groups, salivary sialic acid concentrations of SA both in human cervical
level decreased in the pre-ovulatory phase mucus (14), and human whole saliva in this phase
(15)
compared to control groups. Nadir level was . Nadir concentration in the ovulatory phase
obvious in the ovulatory phase, and then a sudden was found in this study and this is in accordance
rise was found in the postovulatory phase making with Moghissi and Syner (16). Then a sudden rise
the highest concentration. Fig 1. to peak in the post-ovulatory phase; this is
A high statistically significant difference between probably due to consumption of SA from the
SA conc. in the ovulatory phase and the post- blood by the cell membranes of the growing
ovulatory phase (p= 0.001). Another high follicles where it predominates because SA is a
significant difference was found between the monosaccharide component of cell membranes
(17)
ovulatory phase and the prepubertal group , so the consumed SA in the pre-ovulatory and
(p=0.001). A higher significant difference was ovulatory phases is more than the produced or
found between ovulatory and postmenopausal gained. After the rupture of the dominant follicle
group (p=0.0001). The only non-significant value “ovulation” takes place, the SA will be
was between ovulatory and pre-ovulatory periods redelivered to the blood and the extra
(p=0.973). consumption of SA will be stopped in this phase.
Salivary GAGs in normal young women The fluctuation in SA concentration in the blood
presented a biphasic pattern, with higher will be reflected in saliva. The results of the
concentration values during the second half of the present study disagreed with Calamera et al. (18)
Oral Diagnosis 67
who reported a peak in salivary SA concentrations biochemical monitoring of physiological stress by

in the pre-ovulatory phase and Alagendran et al. Fourier transform infrared saliva spectroscopy.
Analyst 2010; 135: 3183-92.
study (1) who reported a peak in salivary SA
3. Galef BG Jr, Smith MA. Susceptibility of artificially
concentrations in the ovulatory phase. reared rat pups to social influences on food choice.
Glycosaminoglycans Dev Psychobiol 1994; 27: 85-92.
In the present study, GAG showed a comparable 4. Rameshkumar K. Chemical characterization of Bovine
concentration in the ovulatory phase (Bos Taurus) Urine with special reference to
(0.412±0.175) ng/ml, to that of the control groups reproductive behavior. Ph.D Thesis. Tiruchirappalli,
Tamil Nadu, India: Bharathidasan Uzniversity; 2000.
((0.452±0.279) for the pre-pubertal group and
5. Rudney JD. Does variability in salivary protein
(0.445±0.041) for the postmenopausal group) with concentrations influence oral microbial ecology and
the peak GAG concentration in the post ovulatory oral health? Crit Rev Oral Biol Med 1995; 6: 343-367.
phase. These results are so far away from 6. Ogasawara Y, Namai T, Yoshino F, Lee MC, Ishii K.
Alagendran et al. (1) study, in which, the GAG Sialic acid is an essential moiety of mucin as a
content showed a distinct peak at ovulation. hydroxyl radical scavenger. FEBS Lett 2007; 581:
2473-77.
The present results are also a disagreement with
7. Bishop JR, Schuksz M, Esko JD. Heparan sulphate
Giampiero et al. (19), who stated that in the women proteoglycans fine-tune mammalian physiology.
with ovulatory cycles, plasma GAG levels Nature 2007; 446: 1030-7.
differed significantly during menstrual cycle, with 8. Richards JS.Ovulation: new factors that prepare the
increased values at the periovulatory phase (3.5 oocyte for fertilization. Mol Cell Endocrinol 2005;
ug/ml) with respect to the menstrual phase. 234(1-2): 75-9.
9. Navazesh M. Methods for collecting saliva. Ann N Y
Another study did not find consistent variations
Acad Sci 1993; 20: 72-7.
during the normal menstrual cycle (20). In contrast, 10. Tram T H, J C Brand Miller, Y McNeil, P McVeagh.
a significant variation in the urinary GAG Sialic acid content of infant saliva: comparison of
concentration during ovulation was reported by breast fed with formula fed infants Archives of
Carranco et al. (21), this peak of maximal GAGs Disease in Childhood 1997; 77: 315-8.
concentration (106.7 ± 46.2 micrograms/mL in 11. Salvolini E, Mazanti L, Martarelli D, Di Giorgio.
Changes in the composition of human unstimulated
urine) was noticed during the ovulatory phase.
whole saliva with age. Aging (Milano) 1999;
In this research, the peak GAG concentration is in 11(2):119-22.
the post ovulatory phase (0.558± 0.218)ng/ml, this 12. Dezan CC, Nicolau J, Souza DN, Walter LRF. Flow
could be due to the release of follicular fluid with rate, amylase activity, and protein and sialic acid
its GAG content after rupture of the follicle to the concentrations of saliva from children aged 18, 30 and
blood stream which will be reflected in saliva. 42 months attending a baby clinic. Archives of Oral
Biology 2002; 47(6): 423-7.
Another possible cause to the reduced GAG
13. Narhi Timo O, Tenovuo J, Ainamo A, Vilja
concentration in the first half of the menstrual P.Antimicrobial factors, sialic acid and protein
cycle, and its increase in the post-ovulatory phase concentration in whole saliva of the elderly. J Dent
is that heparenase enzyme (HSPE) is transiently Res 1994; 102: 120-5.
induced by luteinizing hormone during the 14. Carlborg L, Johansson ED, Gemzell C. Sialic acid
ovulatory process and may be down-regulated by content and sperm penetration of cervical mucus in
relation to total urinary oestrogen excretion and
the increasing progesterone levels in the luteal
plasma progesterone levels in ovulatory women. Acta
phase (22). Endocrinol (Copenh) 1969; 62: 721-31.
On the basis of the results arrived at, the study 15. Oster G, Yang SL. Cyclic variation of sialic acid
concluded that SA and GAGs were probably content in saliva. Am J Obstet Gynecol 1972; 15: 190-
brought under the influence of cyclic variation of 3.
ovarian hormones. There are remarkable cyclic 16. Moghissi KS, Syner FN. Cyclic changes in the amount
and sialic acid of cervical mucus. Int J Fertil 1976; 21:
variations in sialic acid and GAGs during the
246-50.
menstrual cycle but in conclusion, GAGs and 17. Rudong Xing, Yuzhuo Zhang, Zhisan Wang, Ruimei
sialic acid cannot be used for the precise Chen. Serum sialic acid level in patients with oral and
prediction of ovulation. maxillofacial malignancy. J Oral maxillofacial
Surgery 1991; 49: 843-7.
18. Calamera JC, Vilar O, Nicholson R. Changes in sialic
REFERENCES acid concentration in human saliva during the
1. Alagendran S, Archunan G, Velayutha S Prabhu, menstrual cycle. Int J Fertil 1986; 31(1):43-5.
Enrique B, Orozco A and Rosalinda Guevara Guzman. 19. Giampiero Capobianco, De Muro Pierina, Cherchi
Biochemical evaluation in human saliva with special Gian Mario, Formato Marilena, Lepedda Antonio
reference to ovulation detection. Indian J dental Res Junior, Cigliano Antonio et al. Plasma levels of C-
2010; 21(2):165-8. reactive protein, leptin and glycosaminoglycans during
2. Khaustova S, Shkurnikov M, Tonevitsky E, spontaneous menstrual cycle: differences between
Artyushenko V, Tonevitsky A. Noninvasive
Oral Diagnosis 68
ovulatory and anovulatory cycles. Educus 2010; method for ovulation detection. Int J Fertil 1992; 37:
282(2): 207-13. 209-13.
20. Erickson DR, Ordille S, Martin A, Bhavanandan VP. 22. Eyal Klipper, Ehud Tatz, Tatiana Kisliouk, Israel
Urinary chondroitin sulfates, heparan sulfate and total Vlodavsky, Uzi Moallem, Dieter Schams,Yaniv
sulfated glycosaminoglycans in interstitial cystitis. J Lavon, David Wolfenson, and Rina Meidan. Induction
Urol 1997; 157: 61-4 of Heparanase in Bovine Granulosa Cells by
21. Carranco A, Reyes R, Huacuja L, Guzmαn A, Delgado Luteinizing Hormone: Possible Role during the
NM. Human urinary glycosaminoglycans as accurate Ovulatory Process. Endocrinology 2009; 150: 413-21.
Figure 1: Saliva SA level in Control and Experimental Groups (mean± SD)
Figure 2: Saliva GAGs level in control and experimental groups (mean± SD)
No significant correlation was found between SA and GAGs in all the study groups.
Oral Diagnosis 69
J Bagh College Dentistry Vol. 24(2), 2012 Temporomandibular disorders
Temporomandibular disorders in association with stress

among students of sixth grade preparatory and students of
fifth year high schools
Toka T. Alnesary, B.D.S. (1)
Rafil H. Rasheed, B.D.S., M.Sc. (2)
ABSTRACT
Background: A close relationship had been reported between depression, anxiety and many disease symptoms or
disorders. This is true for temporomandibular disorders which is a collective term embracing a number of clinical
problems that involve the masticatory musculatures, temporomandibular joint and associated structures, or both. This
study designed to evaluate the association of stress with temporomandibular disorders among sixth grade
preparatory students and students of fifth year of secondary school.
Subjects, materials and methods: The sample's size of 404 students of sixth grade preparatory study (154males and
250 females) and 360 (168males and 192females) of fifth year of secondary schools. Firstly all the students subjected
for stress questionnaire, secondly the stressful students subjected to different combination of clinical and
questionnaire measures according to the research diagnostic criteria of temporomandibular disorders (axis I) which
have standardized series of diagnostic tests based on clinical signs and symptoms. Data are analyzed by using Z-test
and chi-square.
Results: The results obtained from this study showed that no significant differences between classes in the percentage
of stressful students with temporomandibular disorders according to the clinical examination but in both classes,
females' students showed higher percentage of temporomandibular disorders than males of same class. Bruxism and
nail biting were significantly higher among students of sixth grade.
Conclusions: This study revealed that stress of studying at sixth grade has no effect on temporomandibular disorders
prevalence.
Keywords: Stress, temporomandibular disorders, myofascial. (J Bagh Coll Dentistry 2012;24(2):70-74).
INTRODUCTION
Temporomandibular joint (TMJ) should not be Research findings have supported a
isolated or excluded from being associated with relationship between anxiety, muscular tension,
other joints disorders but fortunately the and TMD symptoms, the psychological status
temporomandibular disorders (TMDs) could be an assessment showed that 39.8% of patients
early exploration to other joint disorders1 with TMD experienced moderate to severe
Temporomandibular disorders are a collection depression, and 47.6% had moderate to severe
of disorders involving the temporomandibular nonspecific physical symptom scores
joint, the soft tissue structures within the joint, (somatization) 9.
and the muscles of mastication 2. The importance of psychological factors in the
The etiology of these disorders is etiology of TMD has usually been
multidimensional. Biomechanical, neuromuscular, emphasized; they are believed to predispose the
biopsychosocial, and neurobiological factors may individual to chronicity 10.
contribute to TMDs 3. These factors are initiating Temporomandibular disorders are often
and aggravating (parafunctions, hormonal, or associated with somatic and psychological
psychosocial factors) to emphasize their role in complaints, including fatigue; sleep disturbances,
the progression of TMD 4. Some studies revealed anxiety, and depression 9, 11. Thus, considering
that occlusal factors were only weakly associated that stress is associated with psychological
with TMD signs and symptoms 5, 6. Moreover, disturbances such as anxiety and depression 12.
there are people classified as bruxers, who did not
present history of pain in masticatory muscles 7, 8. MATERIALS AND METHODS
There is currently considerable evidence that This study was carried out in randomly
psychological factors are of importance in the selected secondary schools of Baghdad city for
understanding of TMD. evaluation the association of stress with TMDs in
students according to the research diagnostic
criteria of TMD (RDC/TMD axis I).
(1) M.Sc. Oral Medicine, Ministry of Health, Iraq. The sample's size of 404 students of sixth
(2) Professor, Dean of College of Dentistry, University of Al- grade preparatory study (154 males and 250
Anbar, Iraq
females) and 360 (168 males and 192 females) of
fifth year of secondary schools.
Oral Diagnosis 70
Subjects gave their informed consent and the The patients were asked about any bad oral
local ethical committee approval. habits with observation their evidences.
The students subjected for stress questionnaire
which consist of 20 questions a score of 7 or more RESULTS
is considered positive for a potential psychiatric There were significant differences between
problem. Then the stressful students subjected to classes in percentage of stressful students by self-
different combination of questionnaire and report stress,. In this study from all selected males
clinical measures according to RDC/TMD (Axis of fifth year there were 21 (12.5%) stressful
I). students and from selected females of fifth year
The stressful students whom subjected to there were 117(60.9%) stressful students, so the
clinical examination had no history of head injury total number of stressful students in the fifth year
and without orthodontic treatment, dental pain, of secondary study was 138 (38.3%) from 360
muscle tenderness due to systemic diseases as students were subjected to self report
fibromyalgia, neuralgia or local infection and had questionnaire, while in the six grade of secondary
no more than 2 missing posterior teeth. study the percentage of stressful students were
The stressful students who had pain in the higher than those in fifth year as follow: stressful
face, jaw, temple, priauricular or in the ear and males were 62(40.3%) and 214 (85.6%) stressful
headaches or migraine or pain that limit these females, so the total number of stressful students
activities: chewing, exercising, eating hard or soft in sixth grade was 276 (68.3%) These findings
food or drinking, smiling, oral hygiene, yawning were listed in table (1).
and talking and those who had clicking, bruxism But there were no significant differences
and oral habit were asked about: the pain history between classes in percentage of stressful students
with conformation of pain location plus palpation had TMDs according to the clinical examination,
of masticatory muscle sites, results in report of In this study from all selected students of fifth
familiar pain13, and asked about jaw locking or year there were 10 (5.9%) males and 45(23.4%)
catching that interfere with eating females had TMD by clinical examination, so the
The students with positive answer subjected to total number of the stressful students with TMDs
clinical examination, these include ear by clinical examination in the fifth year of
examination, cervical examination, and secondary study was 55 (15.2%) which was less
determination of masticatory muscles pain during than students in the six grade where TMDs
active mouth opening (un-assisted mouth showed 63(15.5%) which divided into 12 (7.7%)
opening) and passive mouth opening (assisted males and 51 (20.4%) females, and these findings
mouth opening).This accomplish by Palpation the were listed in table (2).
TMJ (lateral pole) during opening and closing The number of students in the fifth year who
three times at least to detection the joint sound. had myofascial pain (and some of them had MFP
Then determination of masticatory muscles and in combination with other TMDs) was (52), which
TMJ pain during excursive movement of was more than those in sixth grade (48) and the
mandible, with determination of joint sound on differences were significant, while the disc
excursive movement of mandible by stethoscope displacement with reduction was (6), the disc
placed on lateral pole of TMJ 14 displacement without reduction was (6) and
Tenderness of TMJs needs to be palpated in arthralgia also was (6) presented in less
three locations. Tenderness in one of these numbering the students of fifth year in
locations is not necessarily associated with comparison to those of sixth grade (8,15,12)
tenderness in another. Pain or tenderness can respectively but the differences were not
occur in static position or during opening and significant.
closing the mouth. palpation of the first location It had been found that percentage of sixth
by asking the patient to open approximately 20 grade students with deflection (57.1%) was higher
mm and palpating the condyle’s lateral pole, then than that in the fifth class students (50.9%), and
by asking the patient to open as wide as possible the percentage of sixth grade students with nail
while palpating the depth of depression behind the biting (34.9%) was higher than that in the fifth
condyle with fingertip, finally with the finger in class students (9.1%) with significant differences.
the depression and the mouth open wide, by
pulling forward to load the posterior aspect of the
condyle via external auditory meatus using the DISCUSSION
small finger. This study revealed that most of students in the
secondary school were under stress and the
differences were highly significant (P value =
Oral Diagnosis 71
0.001) between fifth (38.3%) and sixth grades is in agreement with other reports in the literature
(68.3%). Yusoff et al., 201115 in previous study 28, 29
.It has been stated that these sex differences
found that the prevalence of distressed secondary could probably be explained by mental factors i.e.
school students in Malaysia was 32.8%. Other young females seem to present a lower pain
previous studies reported that over one-third of threshold 28. Kuttilla et al., found that females
adolescents were under stress 16, 17. Many of these showed more signs and symptoms of TMD, and it
emotional disturbances seem to be caused by seems to be explainable by their higher stress. The
school-related stress such as inappropriate higher prevalence of TMD in females than in
workloads or assignments, examinations, falling males has been attributed to an interaction of a
behind compared to others and inappropriate variety of factors ranging from biological and
treatment by teachers 16 Several authors have hormonal factors to psychological and social ones.
observed that the prevalence of psychological In this study the students who were recorded
distress is higher among students than among with myofascial pain more than students with
working nonstudent populations of the same sex other TMDs even those students with MFP alone
and age 18 or in combination with other TMDs. Lobbezoo et
By clinical examination it had been shown that al., (2004) revealed that between 50% and 70% of
the prevalence of TMDs in stressful students of all patients with TMDs reported masticatory
fifth and sixth year of secondary study was nearly muscle pain,
equal (15.2%, 15.5%), although the percentage of Deflection (57.1%, 50.9%) and midline
stressful students in sixth grade was significantly deviation (58.7%; 61.8%) were reported in both
higher. This percentage was lower than that sixth class and fifth class respectively, which were
observed in another studies 19, 20, 21 and showed higher than that observed by other study (Feteih,
agreement with similar result reported by 22, 23.The 2006). Several studies failed to find strong
large frequency ranges for signs and symptoms of evidence to support the theory that occlusion
TMD previously described in reviews are plays a role in the etiology of TMD, particularly
apparently based on very different samples (e.g. as the sole cause or the dominant factor 32, 33.
random , non-random, different ages, age ranges, While Gesch et al., (2004) reported a weak
sample size, ratio of gender distribution) and association between malocclusion and the
different examination methods (e.g. kind of functional and clinical parameters of occlusion as
variable, method of data collection) 24. well as subjective TMD.
The role of stress and personality in the Oral habits (nail biting) was also reported in
etiology of the temporomandibular pain this study and showed higher percentage among
dysfunction syndrome has undergone extensive students of sixth (34.9%) than students in the fifth
scrutiny. There is considerable evidence that class (9.09%) with significant difference. Other
psychological and psychosocial factors are of study reported lower percentage than that of
importance in the understanding of TMD as with students in sixth class 20.
other chronic pain disorders 25 but there is less The higher frequency of nail biting that had
evidence that these factors are etiologic. Even been recorded at clinical examination may explain
though studies have indicated the role of stress in the higher percentage of students at sixth class
the etiology of TMD, the issue of whether with disc displacement without reduction,
psychological factors cause TMD or reflect the arthralgia and disc displacement with reduction.
impact o TMD on the person remains unknown, There is currently considerable evidence that
due largely to the absence of longitudinal psychological factors are of importance in the
incidence studies designed to test the relationship understanding of TMD. The issue of whether
of the onset of TMD pain to the onset of psychological factors cause TMD or reflect the
psychological and psychosocial factors. Several impact of TMD on the person remains unknown,
studies have assessed the relationship between although there is strong evidence that some
TMD and stress, these studies have had patients with TMD are more anxious and/or
shortcomings, e.g., assessment of acute stress, depressed compared with asymptomatic controls.
limited sample size, nonstandardzed examination, Research findings have supported a relationship
no controls12, 26, 27 between anxiety, muscular tension, and TMD
Although some reports noted no sex symptoms 35.
differences in the prevalence of TMD 20, 23, this
has not been the case for some of the signs and
symptoms in the present study. Generally females
have more signs and symptoms than males. This
Oral Diagnosis 72
Government Secondary School: Initial Findings.

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Oral Diagnosis 73
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Table 1: The differences between classes in the percentage of stressful students by self report
stress
5th secondary 6th secondary
Sex
Total No.with stress % withy stress total No.with stress % withy stress
Male L68 21 12.5 154 62 40.3
Female 192 117 60.9 250 214 85.6
Total 360 138 38.3 404 276 68.3
P value 0.0001*
*Significant using Z-test at 0.05 level of significance
Table 2: The differences between classes in percentage of students had TMDs according to
clinical examination
5th secondary 6th secondary
Sex No. with % with TMD by clinical No. with % with TMD by clinical
total Total
TMD examination TMD examination
Male 168 10 5.9 154 12 7.7
Female 192 45 23.4 250 51 20.4
Total 360 55 15.2 404 63 15.5
P
0.336
value
*Significant using Z-test at 0.05 level of significance
Oral Diagnosis 74
J Bagh College Dentistry Vol. 24(2), 2012 Histological evaluation
Histological evaluation of osseointegration around

titanium implants in thyroidectomized rabbits
(experimental study).
Zaid M. Ali, B.D.S., M.Sc. (1)
Nada M. H. Al-Ghaban, B.D.S., MSc., Ph.D. (2)
ABSTRACT
Background: Thyroid hormones are essential for linear growth and peak bone mass acquisition. Hypothyroidism
occurs when the thyroid gland produces less than the normal amount of thyroid hormones. The present study was
carried out to evaluate the effect of hypothyroidism on osseointegration around the titanium implants screwed in
rabbit's tibia.
Materials and methods :Fifty four machined surface Iraqi implants were inserted in 27 male rabbits (2implants in each
rabbit's tibia ).Eighteen of these rabbits were subjected to near total thyroidectomy to induce hypothyroidism three
weeks before implantation surgery. While the remaining 9 rabbits were remain as a control group. Blood sample was
taken from each animal at the beginning of this study in order to find the normal range of T3,T4,and TSH .And another
blood sample was taken for experimental groups to find the levels of T3,T4,and TSH three weeks after thyroidectomy
in order to assess the hypothyroidism status .After 2, 4, 6 weeks after implant surgery (6rabbits from experimental
group and 3rabbits from the control group) were sacrificed. In the day of scarification, one of the screws was
unscrewed with a torque meter, and the peak torque required to shear off the implant was recorded. Then the
decalcified sections of the bone around the implants were studied histologically and histomorphometrically .The eye
piece reticule was used for morphometrical studies, which were includes: number of osteocytes, number of
osteoblasts, thickness and number of bone trabeculae, and thread width
Results:The results showed that hypothyroid rabbits had delay in osseointegration, bone formation and maturation
around implants in almost all rabbits in experimental groups. While the rabbits in the control groups showed
improvement in osseointegration around titanium implant. Removal torque test illustrated higher torque test value in
control animals than in experimental one. Moreover, there were increases in torque test values in both groups with
time. Biochemical serum analysis revealed a decrease in T3, T4, and increase TSH levels in experimental animals.
Conclusion: It can be concluded that there were low bone quality with a delay in bone healing around titanium
implants in hypothyroidied rabbits compared with healthy one.
Key words: Hypothyroidism, Titanium implants, Rabbits tibia, Osseointegration. (J Bagh Coll Dentistry 2012;24(2):75-
79).
INTRODUCTION
Dental implant treatment has revolutionized oral Therefore, the capacity of bone tissue to respond
rehabilitation in partially and fully edentulous to injuries such as fracture or implant placement is
patients. When the concept of osseointegration associated with several mechanisms and may be
was introduced in relation to titanium endosseous affected by different conditions (3).
implants (1).It became possible to achieve high Thyroid hormones are the major regulators of
success rates in association with this treatment bone metabolism and development.
modality, and multiple investigations have Hypothyroidism is a condition in which the
demonstrated an excellent long-term prognosis. thyroid gland does not make enough thyroid
The achievement and maintenance of hormone (A deficiency of thyroid hormone) to
osseointegration are highly dependent on bone meet the body’s needs. Without enough thyroid
quality and quantity. The systemic conditions may hormone, many of the body’s functions slow
be correlated with impaired bone healing around down. The scientific consensus is that untreated
titanium implants, especially in metabolic bone hypothyroidism causes an abnormally decreased
diseases such as osteoporosis, diabetes mellitus, bone density coupled with poor bone quality, and
and hypothyroidism (2). have been linked to altered osteoblast and
Bone is a highly metabolically active tissue in osteoclast activity, leading to an imbalance in
which the processes of osteoblastic bone bone turnover (4).
formation (anabolic activity) and osteoclastic Although thyroid dysfunctions may affect bone
resorption (catabolic activity) are continuous metabolism via their effect on thyroid hormone
throughout life. levels that influence bone turnover (5) there is a
lack of information regarding the effect of
(1) M.Sc.student, Department of Oral Histology and Biology, changes in T3 and T4 serum levels on bone
College of Dentistry, University of Baghdad
(2) Ass.Professor, Department of Oral Histology and Biology,
healing around titanium implants. Thus, the
College of Dentistry, University of Baghdad objective of this study was to clarify the
establishment and maintenance of
Oral Diagnosis 75
osseointegration in thyroidectomy –induced Histomorphometrical analysis

hypothyroidism in rabbit’s tibia. Trabicular thickness and number
The results showed that there were
MATERIALS AND METHODS significant(P≤0.01) decrease in the trabecular
Twenty seven male adult New Zealand white bone thickness in experimental group compared
rabbits aged from 9 to 12 months were used as to their control in the 6th weeks interval only
animal model in this study. Their weights ranged (Table. 2).While there were no significant
between 1.5 to 2.5 kg .The animals were kept differences in the trabecular number between the
under the supervision from staff of the animal’s experimental and control groups in all healing
house of the College of Veterinary medicine. The periods (Table .3).
animals of this study were divided into two
groups, experimental group (18 rabbits) and Table 2: Trabecular bone thickness (µm)
control group (9 rabbits) .The animals of group
experimental group were subjected to near total control experimental P- value
thyroidectomy to induce hypothyroidism, three H.P
weeks before implant operation. 2weeks 4.75±0.76 3.75±0.72 N.S
The levels of thyroid hormones (T3, T4, and 4weeks 10.31±1.29 9.16±0.42 N.S
TSH) were detected before and three weeks after 6weeks 14.06±1.07 9.375±0.81 p≤0.01*
the thyroidectomy operation (6).
After 2, 4, 6 weeks intervals, the most distal screw Table 3: Trabecular number in different
was exposed and unscrewed with a torque meter, groups
and the peak torque required to shear off the group
implant was recorded. control experimental P- value
Then the decalcified sections of the bone- H.P
implants block were stained with (H&E) and Van- 2weeks 2.75±0.5 2.60±0.05 N.S
Gieson's stains for histological and 4weeks 5.33±0.76 4.83±0.61 N.S
histomorphometrical studies, which were 6weeks 3.40±0.79 3.0±0.91 N.S
includes: number of osteocytes, number of
osteoblasts, thickness and number of bone Number of osteocytes
trabeculae, and thread width The results denote that there was a highly
The statistical analyses were calculated by SPSS significant(P≤0.01)decrease in the number of
(personal computer) (7). In all multiple osteocyts in 2 weeks of the experimental group
comparisons significant p-value was at (p< 0.05). but there was a significant(P≤0.05) increase in
the number of osteocyte in the period of six weeks
in the experimental group compared with the
RESULTS control group (Table .4) .
Torque removal test
The lowest mean torque values for both groups Table 4: Osteocytes number in different
were recorded in 2 weeks while the highest mean groups
value was detected in 6 weeks. Also there was a group
significant (P≤0.01) decrease in the torque values control experimental P- value
of the experimental groups compared with their H.P
controls for healing period (Table. 1). 2weeks 27.33±1.76 16.33±2.60 P≤0.01**
4weeks 31.67±3.3 28.60±2.1 N.S
Table 1: Torque test values of different 6weeks 21.67±0.9 26.75±2.21 P≤0.05*
groups
group Number of osteoblast:
control experimental P- value The results showed that there is there was a
H.P highly significant decrease (P≤0.01) in the
2weeks 9.83±0.50 4.77±1.16 P≤0.01* number of osteoblasts in the experimental groups
4weeks 18.83±1.17 10.0±0.38 P≤0.01* as compared with their controls in all healing
6weeks 23.44±0.78 14.0±1.4 P≤0.01* periods (Table. 5).
Oral Diagnosis 76
Table 5: Number of osteoblast in study

groups
group
experiment
control P- value
al
H.P
2weeks 29.5±1.56 26.33±0.72 P≤0.01*
4weeks 25.66±1.04 22.66±1.53 P≤0.01*
6weeks 20.33±1.26 16.33±1.53 P≤0.01*
Figure 2: Experimental group at 2weeks
Thread width
duration showing newly formed bone
The results indicate that there was a significant
reduction in thread width of experimental animals trabecule(B.T) (Van-gieson's stain X 200).
of 4 and 6 weeks healing periods when compared
with their controls (Table .6 ) .
Table 6: Thread width in study groups (µm).

group
control experimental P- value
H.P
2weeks 18.125±2.13 17.5±1.44 N.S
4weeks 21.875±1.88 18.75±7.2 P≤0.05*
6weeks 26.5±1.27 20.625±0.63 P≤0.01**
Figure 3: Control group at 4weeks duration
Histological findings: showing osteoblast (OB),
The histological findings in 2-weeks interval osteocytes(OS).(H&E X200)
showed large and numerous bone trabeculae in
control group, while there was few and small
bone trabeculae in the thread of experimental
group (Figures 1,2). The histological appearance
of 4-weeks interval revealed immature bone
which almost fill the whole thread in control
group (Figure.3), while in the experimental group
of the same period showed that there was fibrous
connective tissue in near the implant surface with
immature bone (Figure.4,5). Figure 4: Experimental group in 4weeks
The histological picture of 6-weeks interval of the
duration Showing preosteocytes
control group illustrated mature bone with
(POS),osteoclast(OC) (H&E X200).
numerous incremental lines that fill the whole
thread of cortical bone region(Figure 6), and
thick bone trabeculae near the implant surface in
the bone marrow region (Figure 7). While the
picture of experimental group of the same period
revealed still immature bone that fill the whole
thread in the compact bone region (Figure 8).
Figure 5: Experimental group at 4weeks

duration showing immature compact bone
with large size osteocytes (OS),
preosteocytes(POS) (Van-gieson's stain
X400).

showing osteocytes(OS) inside bone
trabecule (Van-gieson's stain X200).
Oral Diagnosis 77
Histomorphometrical analysis:
T3 regulates the differentiation of osteoblasts,
by increasing the expression of many genes of the
osteoblastic phenotype like osteocalcin,
osteoprotegerin ,and this may explain the
decreased number of osteoblasts in the
experimental groups in all the study periods
compared with their controls (10).
Because of ostecytes are derived from
osteoblasts(11) , the effect of thyroid hormones
reduction on osteoblasts can be seen in osteocyte
.Revealing mature bone thread with
numbers in the experimental groups. Also this
numerous incremental lines (arrows) (H&E study showed decrease in trabecular thickness and
X400). numbers in the hypothyroid animals than controls
.This most probably due to low bone turnover in
hypothyroisim which affect both bone resorption
and bone formation and cause reduction in osteiod
apposition (12).
Hypothyroidism resulted in less newly formed
bone within the implant threads and this may
explain the reduction in thread width of new bone
formed around the implant screwed in the
experimental animals. This finding agree with
Wilkins et al(13).
Figure 7: Microphotograph of the control
group at 6weeks duration revealing bone Histological and histochemical findings:
trabecule in bone marrow region Outline the The histological finding of control rabbits of
thread (Van-gieson's stain X200). 2weeks interval showed newly formed woven
bone with new bone trabeculae .While the
hypothyroid rabbits showed generalized delay in
bone remodeling in comparison with control
rabbits. This finding may be due to the fewer
number of active osteoblasts in the hypothyroid
rabbits which are responsible for the formation of
new bone matrix. This finding agrees with
Williams (14)
The histological picture of control animals at
4weeks duration manifested dense newly formed
bone rather than trabecular appearances, and
Figure 8: Experimental group at 6 weeks osteocytes were trying to get concentric
showing immature bone with large size arrangement around haversian canal. While in
osteocytes (arrows) (H&E X200). experimental group the newly formed bone had a
trabecular appearance. Osteocytes still irregularly
DISCUSSION arranged. Osteoclasts and reversal lines were
This study showed increase in removal torque widely seen in the newly formed bone which may
value over time for both experimental and control gave the indication of continuous bone
groups. It has been suggested that this increase remodeling. These differences might be attributed
depends on increasing bone-to-implant contact to the decrease in the secretion of T3 and T4 in
with time as a result of progressive bone hypothyroid animals which cause delay in bone
formation and maturation around implant during formation and maturation .This result correlate
healing, which substantially improved the with previous study done by Williams (15).
mechanical capacity (8).On the other hand, the The histological and histochemical findings of the
increased removal torque values for control control animals at 6weeks duration showed almost
animals comparing with hypothyroid animals in mature newly formed bone threads .It had the
all healing periods indicated that hypothyroidism same mature appearance of the original bone
may affect the bone formation and maturation .while in experimental animals of this period, the
around the implants negatively (9). newly formed bone in general was not completely
Oral Diagnosis 78
mature and the osteocytes still irregularly 11. Salman S, Aral F, Boztepe H, Colak N, Omer B,
arranged. These slight differences in bone healing Tanakol R, Alagol F& Uzum K. Evaluation of the
association between bone turnover markers and
between experimental and control in histological
OPG/sRANK-L levels in relation with the changes of
and histochemical findings may be due to the thyroid function in women with thyroid cancer.
effect of hypothyroidism on bone healing around European Congress of Endocrinology .Endocrine
titanium implants (13,15). Abstracts 2009; 20:P238.
It was also shown that an imbalance in the levels 12. Feitosa DS, Bezerra BD, Ambrosano GM, Nociti Jr
of T3 and T4 correlated positively with the levels FH, Casati MZ , Sallum EA,Toledo SD. Thyroid
of the factors involved with bone homeostasis. Hormones May Influence Cortical Bone Healing
For instance, a decrease in osteoprogenitor cells, Around Titanium Implants. J Periodontal Res 2008 ;
79:7:881-887.
growth factors, and cytokines, resulting in a 13. Wilkins SB, Clark DM, Bain BJ, Bone Marrow
decreased bone apposition, was reported for Pathology. DESEASES OF BONE 2011; P: 469.
hypothyroidism (16). 14. Williams GR, The bare bones of thyroid hormones.
The present study was done to evaluate the effect Endocrine Abstracts 2011; 25: 6.
of thyroid hormones on bone healing around 15. Williams G R, Actions of thyroid hormones in bone.
titanium implants in thyroidectomized rabbits. Polish J Endocrinology 2009;(60)5:380-388.
16. Bonewald LF. Osteocytes In Osteoporosis,3ed.
The findings presented here clearly demonstrate Marcus R, Feldman D, Nelson DA, Rosen CJ, eds.
that clinicians should not underestimate these Burlington. Elsevier Academic Press 2007; 169–190.
conditions when dealing with patients diagnosed
with hypothyroidism that are referred for implant
placement.
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British Dent J 2010; 208: 41 - 42.
2. Kopman JA, Kim DM, Rahman SS, Arandia JA,
Karimbux NY, Fiorellini JP.Modulating the effects of
diabetes on osseointegration with aminoguanidine
anddoxycycline . J Periodontol 2005; 76: 614-620.
3. Ennis BJ. Agglomeration technology mechanism.
Chem. Eng 2010; 117 (3) 34.
4. Little JW.Thyroid disorders. Part I: Hyperthyroidism.
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A, Jafari F, Dehpour AR. Densitometric evaluation of
skull and jaw bones after administration of thyroid
hormones in rats. Dentomaxillofac Radiol 2005;
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6. Edmonds C J, Hayes S , Kermode M , Thompson
BD. Measurement of serum TSH and thyroid
hormones in the management of treatment of thyroid
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Mandalunis P,Bozzini CM, Alippi RM.
Biomechanical performance of diaphyseal shafts and
bone tissue of femurs from hypothyroid rats Endocrine
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10. Freitas FR, Capelo LP, O’Shea PJ, Jorgetti V,
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Oral Diagnosis 79
J Bagh College Dentistry Vol. 24(2), 2012 Prevalence of pulp stone
Prevalence of pulp stone (Orthopantomographic-based)

Zainab H. Al-Ghurabi, B.D.S., M.Sc. (1)
Areej A. Najm, B.D.S., M.Sc. (2)
ABSTRACT
Background: Pulp stones (denticles) are discrete calcified aggregates that occur most frequently in the dental pulp.
It was found in healthy, diseased and sometimes in erupted teeth. Its number appears to increase with increasing
age. It is usually detected during radiographic examination as radiopaque masses of variable size and shape. The
aims of this study were to calculate the prevalence of pulp stones in young Iraqi adults by using digital
orthopantomgraph, and to report any associations between occurrence of pulp stones with, gender, tooth type,
and dental arch.
Subject, Material and Method: A total of 390 digital panoramic radiographs were collected from oral diagnosis
department /College of Dentistry for Iraqi sample, University of Baghdad and Al-Karkh General Hospital. The sample
composed of 169 male and 221 female with mean age (26.9 years). About 10510 teeth were evaluated; pulp stones
scored as present or absent, number of stone and associations with, gender, tooth type and dental arch were
recorded
Result: From 390 (OPG) total of 3758 teeth were examined, 136 patients have pulp stone present in (276) teeth.
According to gender, 75 female with 143 teeth (51.8%) and 61 male with 133 teeth (48.1), that is mean there was no
significant difference of ( pulp stone occurrence) found between female and male. Their presence were seldom
found in the premolars 18 teeth (7%) but was much higher in the molars 258 teeth (93%) and the difference is
statistically significant. Pulp stone occurrence was significantly more common in the first molars than in the second
molars and in the first premolars than in the second premolars in each dental arch. No difference between the two
arches could be identified.
Conclusion: Pulp stones are not only incidental radiographic findings of the pulp tissue but may also be an indicator
of some serious underlying disease. On the other hand, they may provide useful information to predict about the
susceptibility of patients for other dystrophic soft tissue calcifications such as urinary calculi and calcified atheromas.
Key words: OPG radiograph, pulp stone, denticles, prevalence. (J Bagh Coll Dentistry 2012;24(2):80-84).
INTRODUCTION Studies related to the prevalence of pulp stones,

Pulp stones are calcified bodies in the dental pulps based on radiographic examinations, have been
of the teeth in the primary and permanent reported with various percentages (ranging from
dentition. They can be seen in the pulps of 8% to 95%) (1, 8, 9).
healthy, diseased, and even unrequited teeth (1). With age the pulp spaces of teeth decrease in size
Their locations are more common in the coronal through the deposition of secondary and tertiary
than in the ridiculer portions of the pulp and they dentine. When tooth wear, caries or operative
can be observed as free, attached, and embedded intervention is a feature this process becomes
in the dentinal surface of the Pulp chamber. more evident. In most pulps, dystrophic
Pulp stones are classified according to their calcification is found to be of a variable degree,
structure as true, false, and diffuse. They range in and even in teeth without caries or restorations
size from small microscopic particles to large scattered calcification occurs, unrelated to disease
(10)
masses that almost obliterate the pulp chamber (2). . Pulp stones can be structurally classified and
Although the exact cause of pulp calcification is based on location (10,11). Structurally, there are true
unknown some factors have been implicated in and false pulp stones; the distinction being
stone formation such as genetic predisposition (3), morphological. A third type, ‘diffuse’ or
orthodontictooth movement, dentine dysplasia, ‘amorphous’ pulp stones, is more irregular in
dentinogenesis imperfect and in certain shape than false pulp stones, occurring in close
syndromes such as Vandrwoude syndrome (4) association with blood vessels (10, 12). True pulp
circulatory disturbance in pulp, age (5), stones are made of dentine and lined by
interactions between the epithelium and pulp odontoblasts, whereas false pulp stones are
tissue, idiopathic factors (6), and long-standing formed from degenerating cells of the pulp that
irritants like caries, deep restorations, and chronic mineralize (4). Such mineralization occurs in
inflammation (7). stages; initially cell nests become enclosed by
concentrically arranged fibers (i.e. an organic
(1)Assistant lecturer, Department of Oral and Maxillofacial phase precedes mineralization) which then
Surgery. College of Dentistry, University of Baghdad become impregnated with mineral salts. Calcified
(2) Assistant lecturer, Department of Oral and Maxillofacial increments are then added (1,2). Based on location,
Radiology. College of Dentistry, University of Baghdad
pulp stones can be embedded, adherent and free.
Embedded stones are formed in the pulp but with
Oral Diagnosis 80
ongoing physiological dentine formation they ensure of the accuracy of the diagnosis, only the
become enclosed (sometimes fully) within the teeth that were confirmed by our two examiners to
canal walls (10, 13). They are found most frequently have pulp stones were scored as present.
in the apical portion of the root and the presence
of odontoblasts and calcified tissue resembling RESULTS
dentine can occur on the peripheral aspect of these A total of 390 patients (221 females and 169
stones (2). Adherent pulp stones are simply less males) participated in the present study. The age
attached to dentine than embedded pulp stones; range of the subjects was 15 - 50 years, pulp stone
the difference between adherent and embedded were observed in 136 patients with 276 teeth; 75
can be subjective, but adherent stones are never female with 143 teeth and 61male with 133 teeth,
fully enclosed by dentine. Adherent and as shown in table 1.
embedded pulp stones can interfere with root According to the gender the occurrence of pulp
canal treatment if they cause significant occlusion stone in female was slightly higher than in male,
of canals or are located at a curve (10). They may so the pulp stone in female upper 1st molar was
also become dislodged. Free pulp stones are found in 40 teeth (14.9%),while in male 35 teeth
present within the pulp tissue proper and most (12.7%). In female the upper 2nd molar was
commonly seen type on radiographs (10.14). found in 37 teeth (13.4%), while in male was 25
The aim of this radiographic-based study was to teeth (9%). The pulp stone in female upper 1st
determine the prevalence of pulp stones, and to premolar was found in 3 teeth (1.2%), in male was
evaluate possible associations between pulp found in 2 teeth (1.3%), in 2nd upper premolar for
stones and gender, tooth type, and side, and to female was found in 1 tooth (0.3%), while for
compare the results with published data male was found in 2 teeth (0.7%).
presenting a new perspective in forensic medicine. For mandible the 1st molar in female was found in
78 teeth( 28.2%), while in male was found in 43
SUBJECTS AND METHODS teeth (15.5%), lower 1st premolar in female was
A total of 390 digital panoramic radiographs found in 2 teeth (1.3%), in male was found in
(OPG) were collected from oral diagnosis 3 teeth (1.2%), for lower 2nd premolar in female
department /College of Dentistry, University of was found in 3 teeth (1.2%), while in male was
Baghdad and Al-Karkh General Hospital. Digital found in 1 tooth (0.3%).Total number of teeth
panoramic radiographs were taken by using with pulp stone in female was 143 teeth (51.8)
DIMAX3 digital x-ray unit system machine and in male was found in 133 teeth (48.1), as
(Finland). The sample composed of 169 male and shown in table 1.
221 female with mean age (26.9 years). According the arch also the difference between
Information about name, age and gender had been upper and lower arch was very small so the total
recorded for each patient. The digital panoramic number of 1st molar in maxilla was75 teeth
radiographs were examined by two oral and (27.1%), while in mandible was 78 teeth (28.2%),
maxillofacial radiologists at the same time after and 2ns molar in maxilla was 62 teeth (22.4%),
put the radiograph on a viewer; Only Images of while in mandible was 43 teeth (15.5%). The total
good quality which had the clearest reproduction number of 1st premolar in maxilla was 7 teeth
of teeth without any superimposition were (2.6%), while in mandible was 5 teeth (1.5%), and
included. About 10510 teeth were evaluated; teeth 2nd premolar in maxilla was 3 teeth (1%), while in
with crowns or bridges that prevented adequate mandible was 4 teeth (1.4%), the total number in
vision of the pulp chamber were not included in the maxilla was 146 teeth (52.8), while in the
the study sample. Considering that teeth with deep mandible was 130 teeth (47.1) so the difference
fillings and caries lesions are more inclined to between maxilla and mandible was no significant,
have pulp stones, only teeth which were non- as shown in table 1. P=< 0.2
carious and undestroyed, or those with shallow According tooth type the statistic study show that,
fillings, were included. Definite radiopaque Pulp stones were found in only 18 (6.8 %) of the
bodies observed inside the pulp chambers of the premolars and in 258 (93.2 %) of the molars
teeth were identified as pulp stones (Fig. 1,2) and examined, with differences in occurrence being
were scored as present or absent, number of stone statistically significant (p<0.01).The frequency of
and associations with, gender, dental arch and pulp stones was higher in the first molars than in
tooth type were recorded. No attempt was made to the second Molars and in first premolars than in
determine the details of the pulp stones, such as second premolars in each dental arch.
their size, type and location in the pulp chamber
and the condition of the associated tooth. To
Oral Diagnosis 81
DISCUSSION prevalence of pulp stones noted in females and

Calcification in the dental pulp can lead to males in this study agrees with previous studies
denticles, commonly known as pulp stones. They that it is greater in female (1,7,8,16,18).
are hard, bone-like structures that form within the In the present study, the occurrence of pulp stones
pulp of tooth, either within the crown or within was more frequently found in the maxilla than in
the root canals. They are usually detected on X- the mandible in each tooth type and location
ray examination, present as a radiopaque entity in (right- left). In the maxillary arch there are (146)
either the pulp chamber and/or root canal space. teeth with pulp stones while in mandibular arch
They may be either singular or multiple and can there are (130) teeth, so the occurrence is higher
be detected easily unless they are too small or not in maxilla but the difference is not significant
dense enough to show up on an x-ray. Pulp stones statically. These results are in agreement with
are incidental findings and do not need treatment previous studies (1, 17).
and in the literature the incidence of pulp stones In the present study pulp stones were significantly
has been investigated in many histological and more common in first molars than in second
radiological studies based on periapical or molars, premolars and incisors in both maxillary
bitewing radiographs but there is no study and mandibular arches. Also the first premolar is
evaluate the prevalence of pulp stone using the more than second premolar in both arches. This
digital panoramic radiograph (OPG). When the results are in agreement with other studies (1,16-18).
literature related to pulp stones was reviewed, A probable explanation of this result may be
there were a limited number of studies regarding related to the fact that the molars are the largest
the incidence of pulp stones. Moreover, the teeth in the arch, provide a better supply of blood
reported rates of prevalence also differed in the to the pulp tissue and have the strongest chewing
studies. Some researchers reported prevalence force in the arch. This may lead to greater
based on the number of patients and teeth (1), precipitation for calcification (1). Also the early
whereas the others represented only the rates eruption of the first molar will expose them for
based on teeth numbers (8,9,15,16). long period of time to more degenerative changes,
In the present study, we presented rates based thus confirming that calcification of the pulp
both on the number of patients and teeth. On the increases with age.
basis of the number of patients we found the rate
of prevalence to be 34.8%, which is within the REFERENCES
reported range in the literature (1, 9, 17, 18, 19). 1. Sisman Y, Aktan A M, Tarım-Ertas E, Çiftçi M E,
On the basis of numbers of teeth examined, we Şekerci AE . The prevalence of pulp stones in a
Turkish population. A radiographic survey. Med Oral
found 276 teeth with pulp stones and the
Patol Oral Cir Bucal 2011.
percentage is 7.3 %, and this is within the range 2. Johnson PL, Bevelander G. Histogenesis and
reported by other researchers in previous studies, histochemistry of pulpal calcification. J Dent Res
Baghdady et al. in 1988 found (14.8%) out of the 1956; 35:714-22.
6,228 teeth examined in a teenage group of 515 3. VanDenBerghe JM, Panther B, Gound TG. Pulp
subjects. In another study conducted by Al-Hadi stones throughout the dentition of monozygotic twins:
a case report. Oral Surg Oral Med Oral Pathol Oral
and Darwazeh in 1998, the prevalence of pulp
Radiol Endod 1999; 87:749-51.
stones was found to be 22.4 % in 1,028 of 4,573 4. kumar K. Bahetwar A., Pandey K. An unusual case
teeth examined. Ranjitker et al. found the report of generalized pulp stones in young permanent
prevalence to be 10.1 % in 333 out the 3,296 teeth dentition. Contemp Clin Dent 2010; 1(4): 281–283.
examined (17). Another report related to the 5. Hillmann G, Geurtsen W. Light-microscopical
prevalence of pulp stones showed pulp stone investigation of the distribution of extracellular matrix
molecules and calcifications in human dental pulps of
incidence to be 4.8 % in 747 out of the 15,326
various ages. Cell Tissue Res 1997; 289:145- 54.
teeth examined (9). In the present study, we found 6. Siskos GJ, Georgopoulou M. Unusual case of general
that the prevalence of pulp stones was 15 % in pulp calcification (pulp stones) in a young Greek girl.
1,038 of 6,926 teeth examined. Sisman et al. Endod Dent Traumatol 1990; 6: 282-4.
reported 15 % as pulp stone prevalence in molars 7. Sundell JR, Stanley HR, White CL. The relationship
and premolars teeth of Turkish population. of coronal pulp stone formation to experimental
operative procedures. Oral Surg Oral Med Oral Pathol
According to gender, from 136 patients with pulp
1968;25: 579-89.
stones, 75 were females (with 143 teeth have pulp 8. Baghdady VS, Ghose LJ, Nahoom HY. Prevalence of
stones) and 61 were males (with 133 teeth have pulp stones in a teenage Iraqi group. J Endod 1988;
pulp stones), so the female was more than males 14:309-11.
but there are no significant differences between
the genders in each tooth type and arch. The
Oral Diagnosis 82
9. Sener S, Cobankara FK, Akgunlu F. Calcifications of 15. Tamse A, Kaffe I, Littner MM, Shani R. Statistical
the pulp chamber: prevalence and implicated factors. evaluation of radiologic survey of pulp stones. J
Clin Oral Investig 2009; 13:209-15. Endod 1982; 8:455-8.
10. Goga R, Chandler N, Oginni A. Pulp stones: a review. 16. Al-Nazhan S., Al-Shammrani S. Prevalence of Pulp
International Endodontic J 2008; 41: 457–68. Stones in Saudi Adults. ADJ 1991: 129-142.
11. Seltzer S, Bender IB. The Dental Pulp, 3rd ed. 17. Ranjitkar S, Taylor JA, Townsend GC. A radiographic
Philadelphia, PA: J.B. Lippincott Company 1984. assessment of the prevalence of pulp stones in
12. Mjo¨r IA, Pindborg JJ. Histology of the human tooth. Australians. Aust Dent J 2002; 47:36-40.
Copenhagen: Munksgaard, 1973. pp. 61–2. 18. Gulsahi A., Cebeci A., Özden S. A radiographic
13. Philippas GG. Influence of occlusal wear and age on assessment of the prevalence of pulp stones in a group
formation of dentin and size of pulp chamber. J Dent of Turkish dental patients. International Endodontic J
Res 1961; 40: 1186–98. 2009; 42(8): 735–9.
14. Sayegh FS, Reed AJ. Calcification in the dental pulp. 19. Al-Hadi Hamasha A, Darwazeh A. Prevalence of pulp
Oral Surgery, Oral Medicine, Oral Pathology 1968; stones in Jordanian adults. Oral Surg Oral Med Oral
25: 873–82. Pathol Oral Radiol Endod 1998; 86:730-2.
Table 1: Distribution of pulp stone according to arch for both genders

Male Female
Total%
No. % No. %
`1st molar 35 12.68% 40 14.49% 75 (27.1%)
2nd molar 25 9.% 37 13.4% 62 (22.4%)
Maxilla `1st premolar 4 1.4% 3 1.2% 7 (2.6%)
2nd premolar 2 0.7% 1 0.3% 3 (1%)
total 66 23.9% 81 29.1% 146 (53.%)
`1st molar 38 13.76% 40 14.49% 78 (28.2%)
2nd molar 25 9% 18 12.5% 43 (15.5%)
Mandible `1st premolar 3 1.2% 3 1.2% 6 (2.4%)
2nd premolar 1 0.35% 1 0.35% 2 (0.7%)
total 67 24.2% 62 22.8% 130 (47.1)
Total 133 48.1% 142 51.8 100%
P< 0.2
Figure 1: Digital Panoramic Radiograph showing pulp stone.
Figure 2: A: pulp stones in the pulp chamber of maxillary and mandibular second molars.
B: pulp stones in the pulp chamber of maxillary first and second molars. 35% (276 teeth of 136
subjects) with pulp stone
Oral Diagnosis 83
Figure 3: This figure show the percentage of teeth involved with pulp stone.
5% 1s t premolar
55% 1st molar (Red)

38% 2nd molar (Green)
5% 1st premolar (Blue)
2% 2nd premolar (violet)
No significant difference between maxilla and mandible
Figure 4: Pulp stone distribution according to tooth type for both arcs
Oral Diagnosis 84
J Bagh College Dentistry Vol. 24(2), 2012 Evaluation of the haemostatic
Evaluation of the haemostatic action of povidone- iodine in

dental extraction (Clinical and follow up prospective
study)
Ali Q.L. Al-Amiri, B.D.S, M.Sc. (1)
ABSTRACT
Background: This study aimed to evaluate the haemostatic action of povidone-iodine by irrigation of the alveolar
sockets after extraction against the use of normal saline alone.
Materials and Methods: This clinical prospective study included 60 patients (35 males, 25 females), ranging in age
from 20 to 60 years. All minor oral surgery patients at (Oral& Maxillofacial Surgery Department in College of Dentistry/
Babylon University) from March 2011 to January 2012. The patients were divided equally into treatment& control
groups. Povidone-iodine (1%, w/v) was used for irrigation of extraction sockets in the treatment group and saline was
used in the control group.
Results: The 60 patients were divided equally into treatment& control groups. Povidone-iodine (1%, w/v) was used for
irrigation of extraction sockets in the treatment group and saline was used in the control group. In the treatment
group, 24 patients showed cessation of bleeding compared to only 7 in the control group. Povidone-iodine
significantly (P < 0.01) controlled bleeding as compared to saline.
Conclusion: Iodine is corrosive due to its oxidizing potential while povidone is a thickening and granulating agent;
together they have a chemocauterizing effect that could be the reason for the cessation of bleeding.
Keywords: Povidone iodine, Haemostatic action. (J Bagh Coll Dentistry 2012;24(2):85-87).
INTRODUCTION
The use of topical antimicrobial agents is In addition to antibiotic prophylaxis, preparation
common in clean and contaminated surgical of the surgical field with povidone iodine has
wounds, based on the premise that reduction of been widely recommended12.
superficial bacterial contamination aids wound Iodine is corrosive due to its oxidizing potential
healing. Povidone iodine is a widely used and while povidone is a thickening and granulating
highly potent antiseptic. Iodine was first used agent; together they may have a chemocauterizing
medically to produce inflammation and effect that could be the reason for the cessation of
obliteration of serous cavities. It is commonly bleeding6.
used both on intact skin in preparation for surgery In oral surgery, Povidone-iodine is used as an
and on open wounds. Acute lacerations are soaked irrigant of the alveolar sockets following dental
in iodine and surgical wounds are freely irrigated extractions as antiseptic& haemostic. Extraction
with it10. Povidone-iodine is formed by binding of diseased and malformed teeth is an essential
free iodine to polyvinyl-pyrrollidone (PVP), a part of oral surgery. Indications for extraction
solubilizing agent. This is done to decrease the include: end-stage periodontal disease, end-stage
toxicity of the iodine. As iodine is liberated from endodontic disease, pulp exposure when
the PVP molecule it exerts its antimicrobial endodontic treatment is not elected,
effect3. malocclusions, crowding, retained deciduous
Once released, iodine is toxic to microorganisms teeth, trauma, and so forth. The present authors
because it combines irreversibly with tyrosine observed by chance that there was a cessation of
residues of proteins, interferes with the formation fresh bleeding in some patients after irrigation
of hydrogen bonding by some amino acids and with Povidone-iodine5.
nucleic acids, oxidizes sulfydryl groups and reacts For medical uses, saline is often used
with sites of unsaturation in lipids4&7. to flush wounds and skin abrasions. Normal saline
Povidone iodine is a broad spectrum antimicrobial will not burn or sting when applied8.
solution effective against a variety of pathogens Normal saline is isotonic and the most commonly
including Staphylococcus aureus. However, used wound irrigation solution due to safety
similar wound infection rates have been reported (lowest toxicity) and physiologic factors. A
in adult and pediatric populations with saline disadvantage is that it does not cleanse dirty,
irrigation versus 1% povidone-iodine2&13. necrotic wounds as effectively as other solutions
2&13
.
This study aimed to evaluate the haemostatic
action of povidone-iodine by irrigation of the
(1)Assistant Lecturer, Department of Oral & Maxillofacial alveolar sockets after extraction against the use of
Surgery, College of Dentistry, Babylon University. normal saline alone.
Oral and Maxillofacial Surgery and Periodontology 85

MATERIALS AND METHODS postoperative complications were observed in the

This clinical study was carried out on (60) patients of either group.
healthy Iraqi patients who needed dental
extractions. These patients were (35 males, 25 DISCUSSION
females), ranging in age from 20 to 60 years The most common age group involved was 21-
(Table 1-1). All minor oral surgery patients with 30 years; they showed a good response of
multiple extractions (multiple sockets) at (Oral& haemostasis with povidone iodine due to their
Maxillofacial Surgery Department in College of good health status with simple extractions. This
Dentistry/ Babylon University) from March 2011 age group comes into agreement with the age
to January 2012. The patients were divided group of 15-33 years in the study by1
equally into treatment& control groups. The We found in this study, the haemostasis response
alveolar sockets of the treatment-group patients in males was higher than females, and this might
were irrigated immediately after extraction 3 be due to the exclusion criteria in the point which
times by using disposable syringe of (5cc) with is related to females, and this comes into
povidone iodine 1% (w/v) (Betadine, Win- agreement with the study by9 .
Medicare, Germany) plus saline (sodium chloride Povidone is a synthetic polymer of 1-
0.9%, w/v; Parenteral Drugs, Germany) following vinylpyrrollidone, which is hygroscopic and
dental extractions, whereas those of the control- readily soluble in water. It is also a thickening and
group patients were irrigated with saline only. dispersing agent with tablet binding capacity
Spontaneous stoppage of bleeding from the socket (wide firm binding) (SEAN, 2002). Iodine has a
following irrigation was considered as significant corrosive effect on tissues due to its oxidizing
haemostasis. Haemostasis was examined visually. potential11.
Care was taken not to compress the socket to It seems possible that the haemostatic action of
reduce the linear micro-fractures until povidone iodine is due to the corrosive property
observations were made. of iodine and the thickening and binding
All the patients were followed up after 24 hours, properties of povidone. Iodine may chemo-
and blood clot inside the sockets was firm without cauterize the tissues while povidone may aid in
complications. clotting6.
Inclusion and exclusion criteria for the patients We found in this study that 24 patients in the
are listed as follow: treatment group have a haemostasis with
Inclusion Criteria: (Age between 20 and 60 years, irrigation by povidone iodine due to the good
No history of bleeding disorders, No history of health status and simple cases of extractions,
complications of previous extractions). while the other 6 patients have no response to
Exclusion criteria: (Patients on anti-coagulant haemostasis, and the cause might be due to the
therapy, History of hypersentivity to iodine, lower health status when compared with the
Long-term NSAID therapy, menstrual cycle& previous 24 patients. This result comes into
hormonal changes in females, Conditions, such as agreement with the result in the study by8.
periodontitis, gingivitis and dental abscess). While the haemostatic effect of normal saline is
less than that of povidone iodine, because normal
RESULTS saline do not have a chemo-cauterizing action on
The (60) patients were divided into 2 groups the tissues, but just flush the wounds and make
(n = 30), the treatment and control groups; the isotonic action with the wounds. This comes into
control group had 12 women and 18 men, and the agreement with2&13 .
treatment group consisted of 16 women and 14
men (Table 2). REFERENCES
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2. Chisholm CD, Cordell WH, Rogers K, Woods JR.
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by povidone iodine as compared to saline. No Trans Am Acad Opthalmol Otolaryngol 2005; 84: 68–
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4. Gottardi W. Iodine and iodine compounds. In: Block with epinephrine in the treatment of acute bronchiolitis
SS (ed). Disinfection, sterilization and preservation. in the emergency department. J Popul Ther Clin
Philadelphia: Lea & Febiger; 2003. p.183–96. Pharmacol 2011; 18(2): e273–4. PMID 21633141
5. Hellem S, Nordenram A. Prevention of postoperative 9. Sweetman SC (ed). Disinfectants and preservatives.
symptoms by general antibiotic treatment and local In: Martindale the complete drug reference. 33rd ed.
bandage in removal of mandibular third molars, Int J London 2002. p. 1155.
Oral Surg 1973; 2: 273. 10. Senn N. Iodine in surgery with special reference to its
6. Kumar BPR, Maddi A, Ramesh KV, Baliga MJ, Rao use as an antiseptic. Surg Gynecol Obstet 1905; 1: 1–
SN, Meenakshi. Department of Oral and Maxillofacial 10.
Surgery, College of Dental Surgery, Mangalore, 11. Swaryard EA, Lowenthal N (eds). Pharmaceutical
Karnataka, IndiaDepartment of Pharmacology, Necessities. In: Remington's Pharmaceutical Sciences.
Kasturba Medical College, Mangalore, Karnataka, 18th ed. Philadelphia 1990. p. 1307.
India Department of General Surgery, Kasturba 12. Sweet RL, Gibbs RS, Editors, Wound and episotomy
Medical College, Mangalore, Karnataka, India, 2006. infection. In: Infectious Diseases of the female Genital
7. Markham SM, Rock J. Preoperative care. In: Rock JA, Tract 2nd ed. Baltimore: Williams and Wilkins; 2000.
Thompson JD (ed): Te Linde's Operative Gynaecology p. 374–82.
8th ed. Philadelphia: Lippincott-Raven; 1997. p. 233– 13. Watt BE, Proudfoot AT, Vale JA. Hydrogen peroxide
43. poisoning. Toxicol Rev 2004; 23(1): 51-7.
8. Principi T, Komar L. A critical review of a
randomized trial of nebulized 3% hypertonic saline
Table 1: Demography or age range of the patients

Age range Frequency Percentage Treatment group Control group
20 3 5% 2 1
21-30 22 31.7% 17 5
31-40 17 33.3 5 12
41-50 15 25% 4 11
51-60 3 5% 2 1
Total 60 100% 30 30
Table 2: Gender or sex distribution of the patients (Control group& Treatment group)
Number of cases Number of cases
Gender Percentage Percentage
(control group) (treatment group)
Male 18 60% 14 46.67%
Female 12 40% 16 53.33%
Total 30 100% 30 100%
Table 3: The haemostatic action of povidone iodine on the treatment group (significant)
Cessation of bleeding Number of cases Percentage Gender
Yes 24 80% 13males+11females
No 6 20% 1males+5females
Total 30 100% 30
Table 4: The haemostatic action of normal saline on the control group (non significant)
Cessation of bleeding Number of cases Percentage Gender
Yes 7 23.33% 5males+2females
No 23 76.67% 13males+10females
Total 30 100% 30

J Bagh College Dentistry Vol. 24(2), 2012 A comparison between
A comparison between the antibacterial and antifungal

effects of chlorhexidine digluconate (An in vitro study)
Firas H. Qanbar, B.D.S., M.Sc. (1)
ABSTRACT
Background: The use of antimicrobial agent to control plaque and oral disease has been advocated for a number
of years. Different compounds have been delivered through mouth rinses or tooth pastes or by topical application.
The purpose of this research is to find out and to compare between the antibacterial and antifungal properties of
Chlorhexidine digluconate 0.2%.
Materials and methods: Mutans streptococci & Candida albicans were isolated from 25 saliva samples from healthy
volunteers (age range between 21-23 yrs). These isolates were purified and diagnosed according to morphological
characteristics and biochemical tests. Chlorhexidine 2mg/ml (0.2%) was used in the in vitro; susceptibility of Mutans
streptococci and Candida albicans were tested by agar diffusion technique.
Results: Agar diffusion technique showed that Chlorhexidine (0.2%) inhibited the growth of Mutans Streptococci, and
Candida albicans, but the effect of Chlorhexidine (0.2%) on Candida albicans was more patent than on Mutans
Streptococci in vitro. There was statistically highly significant difference (p<0.001) between the antifungal and
antibacterial effects of Chlorhexidine on the sensitivity of the isolates,
Conclusion: Chlorhexidine digluconate 0.2% was more potent as an antifungal than an antibacterial agent.
Key words: Chlorhexidine digluconate, mutans streptococci, Candida albicans. (J Bagh Coll Dentistry 2012;24(2):88-
90).
INTRODUCTION intact mucous membrane linings, or when

The use of antimicrobial agent to control plaque immunologic defects or other debilitating
and oral disease has been advocated for a number conditions exist in the host, these conditions
of years (1). Different compounds have been favorable for fungal infections (7).
delivered through mouth rinses or tooth pastes or
by topical application. Some chemical agents have MATERIALS AND METHODS
proven to be helpful against plaque accumulation Stimulated saliva samples were collected under
and thereby to some extent also against caries (2). standard conditions to obtain 25 microbial
Oral mutans streptococci (MS) are responsible for samples. Volunteers with no medical history aged
50–70% of all cases of bacterial endocarditis. The 21-23 years were selected to participate in this
origins of endocarditis lie in invasion of the study. Each individual was instructed to chew a
vascular system through lesions in the oral piece of Arabic chewing gum (0.4-0.5g) for five
mucosa (3). These streptococci can attach to the minutes to stimulate salivary flow as much as
proteins covering the tooth enamel, where they possible then saliva was collected in sterilized
then convert sucrose into extra cellular screw capped bottles. The collected saliva was
polysaccharides (mutan, dextran, levan) (4). These homogenized by vortex mixer for two minutes.
sticky substances, in which the original bacterial Ten-fold serial dilutions were prepared using
layers along with secondary bacterial colonizers sterile normal saline. Two dilutions were selected
are embedded, form dental plaque. The final for each microbial type and inoculated on the
metabolites of the numerous plaque bacteria are following culture media which are prepared
organic acids that breach the enamel, allowing the according to the manufacturer’s instructions:
different caries bacteria to begin destroying the 1. Mitis-Salivarius Bacitracin Agar (MSB Agar),
dentin (5). the selective media for MS: 0.1ml was withdrawn
A few fungi have developed a commensal from dilutions 10-1 and 10-2 using adjustable
relationship with humans and are part of the micropipette with disposable tips and then spread
indigenous microbial flora (e.g., various species in duplicate by using sterile microbiological glass
of Candida, especially Candida albicans) (6). The spreader on the plates of MSB agar, the plates
first exposure to fungi that most humans were then incubated anaerobically by using a gas
experience occurs during birth, when they pack supplied in an anaerobic jar for 48 hrs at
encounter the yeast Candida albicans (C. 37°C followed by aerobic incubation for 24hrs at
albicans) while passing through the vaginal canal. 37°C.
C. albicans accidentally penetrate barriers such as 2. Sabouraud Dextrose Agar (SD Agar), the
medium is selective for the cultivation and
isolation of C. albicans: 0.1ml was withdrawn
from dilutions 10-1 and 10-2 using adjustable
micropipette with disposable tips and then spread

in duplicate by using sterile microbiological glass acid production from the fermentation reaction
spreader on the plates of SD agar then the plates (Fig. 2).
were incubated aerobically for 48 hrs at 37° C.
A single colony from MS and C. albicans
separately were transferred to 10 ml sterile BHI-B
and then incubated for 24 hrs aerobically at 37°C
to activate the inoculums.
The purity of the isolates was checked by
reinoculation of 0.1 ml of the isolates from BHI-B
suspensions on their selective media by spreader
as mentioned before, then selective colony from
each isolate was transferred to 10 ml of sterile Figure 2: Biochemical identification of
BHI-B and incubated for 24 hrs aerobically at Mutans streptococci.
37°C. One ml from this broth was transferred to A: Positive control tube (agar and bacteria
10 ml sterile BHI-B and then 1 ml sterile glycerol
without mannitol).
was added to the inoculated broth; the tubes were
B: Study tube (agar and mannitol inoculated
labeled (the type of inoculum and the date of
inoculation) and freezed until use. This procedure
with MS).
was repeated twice monthly. A colony was picked C: Negative control tube (agar and mannitol
up from MSB agar and SD agar plates separately without bacteria).
under sterilized conditions and subjected to
gram’s stain; all the isolates were gram positive. C. albicans diagnosed according to morphological
The motility of all types of microbial cells was properties using Gram’s stain (Fig. 3) and germ
examined under microscope by direct smear and tube formation in human plasma.
without staining; the isolates were non- motile.
Catalase production test was performed; a small
amount of pure isolates of MS cultures was
transferred using a sterile loop to the surface of
clean dry glass slide. Drops of hydrogen peroxide
3% immediately placed onto a portion of bacterial
culture on the slide, absence of gas bubbles
indicates the absence of catalase enzyme.
Figure 3: Gram's stain of C albicans showing
gram positive stains (1000x magnification).
All culture media and normal saline were

sterilized by autoclave at 121°C and pressure of
15 pound/inch2 for 15 minutes except for the CTA
medium which was sterilized by autoclaving for
10 minutes. Bacitracin solution was filtered using
Figure 1: MS colonies on MSB agar (20 x
millipore filter size 0.20 µm. Sterilization of all
magnifications).
cleaned glass wares was conducted by hot air
oven at 180°C for 1 hr. Benches and floor of the
Cystine Trypticase-mannitol media had been used
laboratory were disinfected by bleaching
to test the ability of MS to ferment the mannitol
antiseptic solution (Fas).
which was added in a concentration of 1% to the
Agar diffusion technique was applied to study the
Cystine Trypticase Agar media (which was
antimicrobial effects of CHX against the isolates
prepared according to the manufacturer
spread on Brain Heart Infusion Agar (BHI-A);
instructions biomerieux Company), then
wells of equal sizes and depths were prepared in
distributed into screw capped bottles (10ml in
the agar using Kork porer for the evaluation of
each bottle) and autoclaved, each bottle was
CHX. Each well was filled with 50µl of 0.2%
inoculated with 0.1ml of pure MS isolates and
CHX. Plates left for 15 minutes in the room
incubated aerobically at 37°C for 48 hrs.
temperature and then incubated aerobically for 24
Changing in color from red to yellow indicated a
hrs at 37°C. Inhibition zones’ diameters were
positive reaction in comparison to the positive
measured using a scientific ruler.
control (agar and bacteria without mannitol) and
negative control (agar and mannitol without
bacteria) because of pH reduction as a result of

RESULTS biological membranes like ergosterol (8). The

Diameters of inhibition zones for CHX were sensitivity of MS and C. albicans to the aqueous
found to be greater in the plates inoculated with extract of eucalyptus could be due to the
C. albicans than those formed in the plates of MS hereditary contents or attraction ability or the
(Fig. 4). Student’s t-test showed highly permeability of the cell wall of the
significant differences among different CHX microorganisms. CHX disrupts cell membrane
inhibitions’ zones (Table 1). and cell wall permeability of many Gram- positive
Results of agar diffusion experiments are affected and Gram-negative bacteria and interferes with
by many factors like the molecular weights and the adherence of plaque-forming bacteria, thus
concentrations of the antimicrobial agent, the reducing the rate of plaque accumulation (9), it can
types of the isolates and the fluidity and/or inhibit the adenosine triphosphatase (ATPase)
stickiness of the solutions. The thickness of the which is an important enzyme that is linked to
agar was well controlled through out the cytoplasmic membrane and thus can inhibit the
experiment by measuring the volume of the agar process of returning potassium ions into cells in
while it was liquid before poring it into the same exchange for sodium and hydrogen ions, also
sized petridishes in order to avoid the variation of inhibits metabolic enzymes (10).
the results which will appear as a result of agar Differences in the microbial susceptibility to CHX
thickness variations. The size of inoculums was could also be due to the hereditary contents of the
controlled by using adjustable micropipettes with isolates which may alter the susceptibility of the
disposable tips to ensure that equal volumes of the organisms by modifying the targets to be attacked
isolates’ suspensions were dispensed into all the by the active constituents like the proteins and
plates and the same precaution was carried out for lipids of the microbial membrane or inhibiting the
the volumes of the extracts and CHX which were constituents of the leaves' extract or modifying the
dispensed into the wells made in the agar plates. structures of these constituents by some enzymes
rendering them to less effective compounds.
REFERENCES
1. Milner JL, Stohl EA, Handelsman J. A resistance gene
from Bacillus cereus. J Bacteriol 1996; 178: 4266–72.
2. Thylstrup A, Fejerskov O. Textbook of clinical
cariology. 2nd ed. Copenhagen: Munksgaard; 1994.
3. Krasse B. Caries risk: A practical guide for assessment
and control. Chicago: Quintessence Publishing Co;
1985.
Figure 4: Comparison between the mean 4. Genco, VanDyke, 1986. Quoted by Holt JG, Krieg
NR, Sneath PHA, Staley JT, Williams ST.
diameters of inhibition zones of CHX in Bergey's manual of determinative bacteriology. 9th
relation to Mutans streptococci and C. ed. Baltimore & Maryland: Williams & Wilkins; 1994.
albicans. 5. Kayser FH, Bienz KA, Eckert J, Zinkernagel RM.
Medical microbiology. New York: Thieme; 2005. p.
243.
Table1: Statistical analysis for the sensitivity
6. Murphy JW, Friedman H, Bendinelli M. Fungal
of Mutans streptococci, lactobacilli and C infections and immune responses. New York: Plenum
albicans to different concentrations of Press; 1993.
aqueous extract of eucalyptus using 7. Kwon-Chung KJ, Bennett JE. Medical mycology.
Student’s t- test. Philadelphia: Lea & Febiger; 1992.
8. Kayser FH, Bienz KA, Eckert J, Zinkernagel RM.
CHX Medical microbiology. New York: Thieme; 2005, p
Isolates 0.2% 243.
t-value t-value 9. Samaranayake L. Essential microbiology for dentistry.
MS & C. albicans 16.43 0.000 **** 3rd ed. Philadelphia: 2006.
***P<0.001 High significant 10. Autio J. The role of chlorhexidine in caries prevention.
Oper Dent 2008; 33(6): 710-6.
Results showed that there were some differences
in the sensitivity of the isolates to CHX; it can be
explained by the differences between eukaryotic
cells (fungi) and prokaryotic cells (bacteria)
especially of the cell wall. The cell walls
of fungi consist of nearly 90% carbohydrate
(chitin, glucans, mannans) and fungal membranes
are rich in sterol types not found in other

J Bagh College Dentistry Vol. 24(2), 2012 Effect of in-dental clinic
Effect of in-dental clinic bleaching agents on the releases of

mineral ions from the enamel surfaces in relation to their
times intervals
Afnan AL-Shimmer, B.D.S. (1)
Mohammad Al-Casey, B.D.S., M.P.H., M.S.P.H .(2)
ABSTRACT
Background: alterations of the enamel after topical application of bleaching agents, presenting as major
consequences are: ions release, increased superficial roughness, stronger bacterial attachment and hardness
alteration. The aims of the study were to evaluate the effects of two different types of bleaching agents for vital teeth
by using with light source on the release of ions (Calcium and phosphate ions) from the enamel surface.
Materials and methods: Fifty three sound enamel surface for calcium ions release and Fifty three sound enamel surfaces for
phosphate ions, were subject to treated with bleaching agents (35% hydrogen peroxide and carbamide peroxide) and
then application of light and laser radiation to activate the bleaching agents. Spectrophotometer and Buck scientific
atomic absorption spectrophotometer were used to measure the ions release from enamel surface.
Results: highly significant increase in the release of ions (calcium ions), while significant increase in the release of ions
(phosphate ions) in relation to the times intervals.
Conclusions: In this study showed that release of calcium ions from enamel surface after treated with both 35%
carbamide peroxide and 35% hydrogen peroxide increase with increase the time and compared with release of
phosphate ions release and control groups.
Key word: Enamel surface, Ions release, Bleaching agents. (J Bagh Coll Dentistry 2012;24(2):91-93).
INTRODUCTION
In recent years, with more and more people Many authors have demonstrated alterations of
interested in cosmetic enhancement, the demand the enamel after topical application of bleaching
of tooth bleaching is increasing sharply. Not only agents, presenting as major consequences are:
conventional bleaching of non-vital teeth, the ions release, increased superficial roughness,
needs for bleaching of vital teeth is also increase stronger bacterial attachment, hardness alteration,
(1)
Tooth bleaching can be performed externally, color alteration, and adhesion to resinous
termed vital tooth bleaching (2) various methods materials (7) . Research in this area has showed
and bleaching chemicals have been used penetration easily the hydrogen peroxide, because
extracoronally on teeth with vital pulps (3). of its low molecular weight, passes through the
Bleaching systems that act by means of strong enamel and dentin to the pulp(8).
oxidizers are mostly used for brightening of teeth.
Depending on the form of application, the
concentrations lie between 10-35% peroxide. In MATERIALS AND METHODS
particular, 35% concentrated hydrogen peroxide One hundred six non carious maxillary first
or carbamide peroxide are used. The action premolar teeth extracted for orthodontic purpose.
mechanism is based on oxidative discoloration of Teeth were fixed in temporary state in an auto
incorporated colorants. However, strong oxidizers polymerizing resin base (cold cure resin) and
also degrade structure-relevant in the enamel (4). became ready for application. The bleaching
The most popular technique for the in-office process was done according to manufacturers
bleaching of vital teeth involves 35% hydrogen instruction and this done by using a disposable
peroxide, with phosphoric acid to facilitate brush to paint the totally cover the surface of the
bleaching and etching the teeth either a heating tooth and the time of application is 8 min and each
element or a light source to enhance the action of sample three times application of pola office gel,
the peroxide (5). The use of optical radiation in the each samples exposure to 40 second a curing light
so called light assisted tooth bleaching procedure machine and Laser unit used for this study is
has been suggested to enhance effect of the continuous power (CW) Nd-YAG laser for
bleaching agent (6). exposure to the bleaching agent This step was
repeated for four times for each sample as
recommended by the manufacturers instructions
(1) MSc student, Department of preventive dentistry, College of Then the samples were washed using a continuous
Dentistry, University of Baghdad. jet of syringe for one minute to dissolve the
(2) Professor, Department of preventive dentistry, College of bleaching agent on the tooth surface and dried with
air syringe for 30 seconds. Then storages in 10ml of
Orthodontics, Pedodontics, and Preventive Dentistry91

de-ionized water in sterilized glass container and demineralization ( loss of mineral ) result in
returned to incubator in 37Ċ until the time of decreased the enamel microhardness.
testing. This may be due to higher concentration of
Essential elements release from sample in de- peroxide and formed free radical is higher from
ionized water was analyzed at the poisoning laser than from halogen light, so causes more
consultation centre /specialized surgeries hospital demineralization to the enamel ( Loss of calcium
by using Buck scientific atomic absorption ions) this result agree with some study (10,11),
spectrophotometer following standardized concluded that 35% HP with light may cause
procedure. significantly more loss of Ca+2 from the enamel
surfaces than lower concentration CP.
RESULTS The treatment with carbamide peroxide and
For statistical analysis was used in this study: activated with laser and halogen light show in the
means and standard deviation values of ions revealed highly significant different ( P< 0.001 )
release from enamel surface that activated by two for both light source this may be indicated
different light source and for all groups are listed changes in the enamel crystal composition and
in table (1).The data revealed that there was alter enamel structure the result agree with other
increase in ions release values for the sound research ( 12-14) , show that bleaching with
enamel surface over the time for all the groups hydrogen peroxide or hydrogen peroxide
and after bleaching with both 35% carbamide releasing agents may result in significant decrease
peroxide and 35% hydrogen peroxide. Statistical of enamel calcium and phosphate content and
analysis of data by using ANOVA test show in morphological alteration in the most superficial
table (2) revealed that there was a non- significant enamel crystallites. In this study show that
difference (P>0.05) among the control groups, carbamide peroxide causes local microstructure
while highly significant difference (P<0.0001) and chemical changes, such as loss phosphate
among when use light source ( halogen light ) and ions, as show in the ANOVA table, represent
also highly significant difference (P<0.0001) highly significant different between the group at
among the different groups when use light source three period of time for the two activation used (
(laser light) at different period of times for the Halogen light and laser radiation ), this indication
release of calcium ions, while for the phosphate alteration in the composition of enamel these
ions show in the table (3) revealed that there was result agree with other result showed that in-office
a non-significant difference (P>0.05) among the bleaching caused deleterious alterations in the
control groups, while highly significant difference composition and structure of enamel that
(P<0.001) among the different groups when significantly affected the crystalline and
bleaching is done using light source ( halogen mineralization of the tissue(15) . In this study
light ) and also highly significant difference showed that the means of release the calcium ions
(P<0.001) among the different groups when use from sound enamel surface is higher than the
light source (laser light) at different period of phosphate ions as showed in the table (1) this is
times. may be due to the concentration of the calcium
ions is higher than the phosphate ions in the
enamel surface of permanent teeth, this result
DISCUSSION agree with many study (16, 17), Calcium ions
It is obvious from the results of this study the followed by phosphorus ion were the major
enamel surface when treated with 35% hydrogen elements in enamel sample.
peroxide gel and activated with the halogen light
resulted in marked increase in the means of
release of calcium ions at the 96hrs, in compared REFERENCES
1. Rodrigo A, Jose R, Hugo H, Luiz T, Rodrigo C. Effect of
to the control groups. While result found, when
hydrogen peroxide topical application on the enamel and
treated with 35% hydrogen peroxide gel and composite resin surfaces and interface Indian J Dent Res
activated with the laser irradiation for the same 2009; 20(1): 65-70.
period of time ( 96hrs. ), found the means is 2. Watt A, Addy M. Tooth discoloration and staining a
higher than that of halogen light and also much review of literature. Br Dent J 2001; 190(6): 309-16.
higher in compared to control. 3. Goldstein R, Garber D. Complete dental bleaching .1ste
Chicago Quintessence Publishing Co Iinc.1995.ch. 1,2.
This adverse effect of bleaching on the enamel
4. Nakamura T, Saito O, Kong T, Maruyama T. The effects
mineral ( ions ) was noted by many researches, of polishing and bleaching on the colour of discolored
may be due to the concentration or type of the teeth in vivo. J Oral Rehab 2002; 28: 1080-4.
bleaching agent used, this agree with the many 5. Goldstein R, Haywood B. Bleaching teeth: new
study (9), showed that after treatment bleaching materials-new role. J Am Dent Assoc. Quintes Int, 1992;
with high concentration of hydrogen peroxide, 23: 471-88.

6. Bruzell E, Johnsen B, Alerud T, Dahl J, Christensen T. In and dentin microhardness. Opera Dent 2005; 30(5): 608-
vitro efficacy and risk for adverse effect of light assisted 16.
tooth bleaching photochemical Photo biological Sci Dental 13. Lee K, Kim K, Kwon Y. Mineral loss from bovine enamel
Material 2009; 8(13): 377-85. by a 30% hydrogen peroxide solution. J Oral Rehabil
7. Rotstein I, Dankner E, Goldman A, Heling I, Stabholtz A, 2006; 33(3): 229-33.
Zalkind M. Histochemical analysis of dental hard tissues 14. Fu B, Hoth-Hannig W, Hannig M. Effect of dental
following bleaching. J Endod 1996;22:23-5. bleaching on micro and macro-morphological alteration of
8. Oltu U, Gürgan S. Effects of three concentrations of the enamel surface. Am J Dent 2007; 20(1): 35-40.
carbamide peroxide on the structure of enamel. J Oral 15. Severcan F, Gokduman K, Dogan A, Bolay S, Gokalp S.
Rehabil 2000; 27:332–40. Effects of in-office and at home bleaching on human
9. Pinto C, Oliveira D, Cavalla V, Giannini M. Peroxide enamel and dentin: an in vitro application of fourier
bleaching agents effects on enamel surface micohardness, transform infrared study. Department of Biology. Appl
roughness and morphology. J Braz Oral Res 2004; 18(4): Spectro Sc 2008; 62(11): 1274-9.
306-11. 16. Haitham G. Concentration of major and trace elements in
10. Hüseyin T, Ozlem S, Ferit O, Hande D, Ziya O. Effect of permanent teeth and enamel among ( 11-14 ) years old
bleaching agents on calcium loss from the enamel surface. children in relation to dental caries. A thesis submitted to
Quintes Int 2007; 38 (4): 339-471. the college of dentistry university of Baghdad. 2005.
11. Bowles W, Ugwuneri Z. Pulp chamber penetration by 17. Justino L, Tames D, Demarco F. In situ and in vitro effect
hydrogen peroxide following vital bleaching procedures. J of bleaching with carbamide peroxide on human enamel. J
Endod 2001; 8: 375-7. Oper Dent 2007; 29(2): 219-25.
12. Basting R, Rodrigues A, Serra M. The effect of 10%
carbamide peroxide, carbopol and/or glycerin on enamel
Table 1: Descriptive statistics of ions release from enamel surface of all groups in ppm.
Calcium ions Phosphate ions
Groups
Times Mean SD Mean SD
48hours 0.2480 0.0295 0.2480 0.0295
Control group 72hours 0.2772 0.04667 0.2772 0.04667
96hours 0.3350 0.01029 0.3350 0.01029
48hours 0.4625 0.1573 0.6597 0.0208
Laser 72hours 3.1812 0.4805 2.3664 0.2732
35%CP
Radiation
96hours 4.9370 0.5203 4.1357 0.7358
48hours 0.3187 0.2605 0.5885 0.0788
Light
35%CP 72hours 2.3035 0.3229 1.7162 0.1943
cure
96hours 3.2870 0.4148 2.4145 0.6644
48hours 2.4625 0.3433 0.7912 0.0404
Laser radiation 35% H.P 72hours 3.4862 0.3118 1.4092 0.0949
96hours 4.3280 0.2851 2.7112 0.2350
48hours 0.7110 0.0792 0.2652 0.0609
Light cure. 35% H.P 72hours 2.6412 0.3128 1.3780 0.1220
96hours 3.8240 0.5551 1.8406 0.1030
Table 2: ANOVA test for release of ions (calcium ions ) from enamel surface at different period
of time when activated with laser light and halogen light .
Agents df F-test P-values Sig
control 2 7.450 .012 NS
35%H.P
2 35.323 .000 HS**
Act. With laser
35%H.P
2 71.868 .000 HS*
Act. With light
Table 3: ANOVA test for release of ions ( phosphate ions ) from enamel surface at different
period of time when activated with laser light and halogen light .
Agents df F-test P-values Sig
control 2 7.450 .012 NS
35%H.P
2 174.887 .000 HS**
Act. With laser
35%H.P
2 269.106 .000 HS*
Act. With light
HS = Highly significant different (p< 0.0001).
NS = Non signifiant different (p>0.005).

J Bagh College Dentistry Vol. 24(2), 2012 Physicochemical characteristic
Physicochemical characteristic of unstimulated and

stimulated saliva with different chewing gum stimulation
Alhan A. Qasim, B.D.S., M.Sc. (1)
Eman K. Chaloob, B.D.S., M.Sc. (1)
ABSTRACT
Background: Gum chewing is a common habit in many countries. Both sucrose containing and sugar-free gum
stimulate salivary flow, increase in saliva flow lead to more frequent replenishment and greater supply of
antibacterial factors, saline, buffers, minerals and other beneficial constituents, increase pH and buffer capacity of
whole saliva. The aim of the present study was to investigate the effect of different chewing gums on the salivary
constituents including some elements (Magnesium, Calcium, Copper and Zinc)(chemical),PH and flow
rate(physical)characteristic.
Materials and Methods: Saliva samples was collected from dental students/college of dentistry 23 age stimulated by
three types of chewing gum (mastic, Arabic, sugar) and control group (unstimulated saliva), pH and saliva flow rate
was recorded for four groups. Biochemical analysis was assessed for some salivary elements, (Magnesium, Calcium,
Copper, and Zinc) and its relation with different chewing gum and control group. Student's t-test, ANOVA and LSD
test was used for statistical analysis. Also mean and standard deviation was recorded.
Results: Mean value of pH was found to be high in three types of chewing gum with highly significant difference
comparing with control group. A significant difference in flow rate was found between control and sugared gum
group. Mg and Ca ione was found to be highly significant between mastic gum group and other three groups , as
well as highly significant difference was recorded among four groups of saliva in Cu ione, while no significant
difference was showed between Zn ione and four groups.
Conclusion: Chewing gum include natural (mastic and Arabic) and sugared was increases salivary pH. Use of
chewing gum especially mastic and Arabic can enhance the remineralizing potential of the mouth, probably by
stimulating salivary flow which may lead to rise salivary elements.
Key words: Chewing gum, salivary elements, Mastic gum, Arabic gum. (J Bagh Coll Dentistry 2012;24(2):94-98).
INTRODUCTION the secreted saliva and its pH after chewing

Chewing gum probably has its origin in ancient xylitol-containing gum and mastic gum in case
Egypt and in Mayan Indian times as these peoples and control groups.The results indicated that both
are known to have chewed the resin of trees(1)also, mastic gum and xylitol chewing gum increased
in 50A.D.,when the Greeks sweetened their breath the rate of secreted saliva and its pH (7), Another
and cleansed their teeth with arsine called important sugar free gum was Acacia gum
mastiche, which was obtained from the bark of the consists primarily of Arabica, a complex mixture
mastic tree so that the chewing gum first became of calcium, magnesium and potassium salts of
an aid to maintaining oral health(2),in addition to Arabic acid. It contains tannins which are
that chewing gum increases salivary flow rate reported to exhibit astringent, homeostatic and
and enhance the protective properties of saliva healing properties. It also contains cyanogenic
this because the concentration of bicarbonate and glycosides in addition to several enzymes such as
phosphate is higher in stimulated saliva, and the, oxidase, peroxides and pectinases, all of which
resultant increase in plaque pH and salivary have been shown to exhibit antimicrobial
buffering capacity prevent demineralization of properties. Acacia Arabica type of chewing gum
tooth structure. Morevere, the higher has potential to inhibit early plaque formation (8).
concentration of calcium, phosphate, and On other hand most chewing gum is sweetened
hydroxyl ions in such saliva also enhances with sucrose, gum products may increase the
remineralization (3,4)
.Many studies have cariogenic load to dietary carbohydrates (9). The
demonstrated the ability of mastic gum to aim of the present study was to investigate the
suppress the growth of cariogenic bacteria and to effect of different chewing gums on the salivary
reduce the salivary streptococcus mutans constituents including some elements
count(5),as well as another study concept that the (Magnesium, Calcium, Copper and Zinc), PH and
use of mastic gum and xylitol containing chewing flow rate.
gum for 20 minutes after an acidogenic challenge
can enhance the remineralizing potential of the MATERIAL AND METHODS
mouth, probably by stimulating salivary flow (6), The sample of present study composed 80 dental
also a study by Bakhtiari (7)compared the rate of students (college of dentistry, university of
Baghdad) aged 23 years, they were divided in to
(1) Lecturer. Pediatric and Preventive Department. College of four groups, each group consist of 20 sample, The
dentistry, University of Baghdad.
saliva was collected after taking the medical

history and any medical problems or any systemic difference in salivary pH among different type of
diseases were excluded. The collection of chewing gum stimulation ,while the difference
stimulated salivary samples was performed under were not significant, concerning flow rate. Further
standard condition following instruction cited by investigation using L.S.D test revealed that there
(10)
, while the collection of unstimulated salivary is no significant difference between salivary pH,
samples was performed under standard condition flow rate with different chewing gum stimulation
following instruction cited by Tenovuo and Table 2 .The pH of unstimulated saliva was found
Lagerlof (11) in the present study to be 6.8±0556 which was
First group the individuals were asked to collect lower that for stimulated saliva with different type
unstimulated saliva. Second group the individual of chewing gum and this difference were highly
were asked to chew a piece of Mastic chewing significant for Arabic and sugar chewing gum
gum. Third group the individual were asked to (-2.958, -3.039) Table (3), this table also revealed
chew a piece of Arabic gum. Fourth group the the salivary flow rate for unstimulated saliva was
individual were asked to chew sugar gum. For lower than for stimulated saliva with different
these entire 4 groups the chewing was for one chewing gum but these difference were not
minute all saliva was removed by expectoration, significant. Table (4) shows that there is highly
chewing was then continued for ten minutes with significant difference in concentration of Mg, Ca,
the same piece of chewing gum and saliva Cu among different type of chewing gum, while
collected in a sterile screw capped bottle. Salivary salivary Zinc concentration the difference was not
pH was measured using an electronic pH meter significant..Further investigation using L.S.D test
and flow rate of saliva was expressed as milliliter showed that salivary concentration of Mg, Ca and
per minute (ml/min).The salivary samples were Cu were found significantly higher among group
then taken to the laboratory for biochemical with mastic than Arabic chewing gum stimulation,
analysis. Samples were centrifuge by (Gallen while opposite figure found concerning salivary
kamp, England) at 3000 rpm for 30 minutes; the concentration of Zinc with significant difference.
clear supernatant was separated by disposable The L.S.D test also shows that the concentration
micropipette and was divided into 4 portions, of salivary Mg, Ca were highly significant, higher
stored at (-20°C) in a deep freeze till being among group using mastic chewing gum than that
assessed. Biochemical analysis of four elements using sugared chewing gum and opposite figure
of saliva (Calcium, Magnesium, Copper, Zinc) was found concerning concentration of copper as
were done at the Poisoning Consultation Centre / its concentration were highly significant ,higher
specialized surgeries hospital by flame atomic, among group using sugar chewing gum than
using absorption spectrophotometer (Buck group using mastic chewing gum Table 5, this
scientific, 210VGP, USA) following standardized table also revealed that the only significant
procedure. difference was found concentration of salivary
1. Determination of Ca++ :Dilute the samples in copper where company its concentration between
four groups with the lanthanum diluents, mix person using sugar stimulation. Salivary Mg , Ca,
well and take for measurement of calcium by Cu, Zn (mean and SD) among unstimulated and
atomic absorption spectrophotometer stimulated saliva were shown in table 6 that show
(AAS)10.a hollow cathode lamp specific for the mean of salivary Mg, Ca was higher in mastic
calcium was used at a wave length of chewing gum stimulation than that for
422.7nm. unstimulated saliva and these difference were
2. Determination of (Magnesium, Copper, Zinc): highly significant (-7.610, -8.174), also this table
the samples in four groups were diluted with revealed that the mean of salivary Cu was higher
deionised water mix well and take for concentration in sugar and mastic gum
measurement of these elements by atomic stimulation than that for unstimulated saliva with
absorption spectrophotometer (AAS)(12). highly significant difference(-3.023, -11.071),
The data was processed with SPSS 9.0 while significantly salivary Zn concentration was
statistical software. ANOVA (analysis of higher in Arabic chewing gum than that for
variance), LSD test and Student's t-test served unstimulated saliva(-2.413).
for statistical analyses. The significance level
was set at 95% (P<0.05). DISCUSSION
Chewing gum use has a longer period of exposure
RESULTS to the surface of teeth than a dentifrice or mouth
The mean values of salivary pH ,flow rate for rinse; therefore it can be a useful adjunct for
different type of chewing gum stimulation were maintaining oral health, especially if it contains a
shown in table 1that shows highly significant therapeutic agent that is effective topically(13).In

the present study the pH ,flow rate and some a necessity to investigate the effectiveness of this
salivary elements of three types of chewing gum natural product through long-term clinical.
and unstimulated saliva was assessed. The present
study represented that the pH mean of
unstimulated saliva group was found to be lower REFERENCES
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Table 1: Salivary pH and flow rate (Mean ± SD) among different chewing gum simulation
Mastic Gum Arabic Gum Suger Gum ANOVA
Variables
Mean SD± Mean SD± Mean SD± F Sig
pH 7.100 .458 7.275 .454 7.245 .345 4.464* .006
Flow rate 2.910 1.208 2.855 1.234 3.420 1.323 1.369 .259
Highly significant p< 0.01
Table 2: Salivary magnesium, calcium, copper and zinc (Mean ± SD) among different chewing
gum stimulation
Mastic Gum Arabic Gum Suger Gum ANOVA
Variables
Mean SD± Mean SD± Mean SD± F Sig
Magnesium 4.593 2.242 .338 .212 .455 .156 62.509* .000
Calcium 15.200 5.207 4.580 1.477 3.190 .748 70.657* .000
Copper 53.500 13.869 25.500 6.863 75.000 10.000 83.572* .000
Zinc 16.000 9.403 21.500 8.127 15.500 7.591 2.540 .063
Table 3: LSD test of PH and flow rate among different chewing gum stimulation
Mastic &Arabic Gum Mastic &Suger Gum Arabic &Suger Gum
Mean Sig Mean Sig Mean Sig
pH -.175 .232 -.145 .322 .030 .837
Flow rate .055 .893 -.510 .216 -.565 .171
Table 4: LSD test of salivary electrolytes among different chewing gum stimulation
Mastic &Arabic Gum Mastic &Suger Gum Arabic &Suger Gum
Mean Sig Mean Sig Mean Sig
Magnesium 4.225* .000 4.138* .000 .117 .745
Calcium 10.620* .000 12.010 * .000 1.390 .140
Copper 28.000* .000 -21.000 * .000 49.000* .000
Zinc -5.500* .037 .500 .848 6.000* .024
Highly significant p< 0.01
Table 5: Salivary Ph and flow rate among unstimulated saliva and stimulated salivary groups
Unstimulated Stimulated
Variables
mean SD Mean SD t-test Sig
1 7.100 .458 -1.861 .071
pH 6.800 .556 2 7.275 .454 -2.958* .005
3 7.245 .345 -3.039* .004
1 2.910 1.208 -.716 .478
Flow rate 2.615 1.391 2 2.855 1.243 -.575 .569
3 3.420 1.323 -1.875 .069
*Highly significant p<0.01

Table 6: Salivary magnesium, calcium, copper and zinc among unstimulated and stimulated
groups
Unstimulated Stimulated
Variables
mean SD Mean SD t-test Sig
1 4.468 2.252 -7.610 .000
Magnesium .777 .491 2 .338 .212 3.667 .001
3 .455 .156 2.792 .008
1 15.200 5.207 -8.174 .000
Calcium 4.856 2.224 2 4.580 1.477 .452 .654
3 3.190 .748 3.163 .003
1 53.500 13.869 -3.023 .004
Copper 42.500 8.506 2 25.500 6.863 6.955 .000
3 75.500 10.000 -11.071 .000
1 15.150 9.783 .126 .900
Zinc 15.500 7.591 2 21.500 8.127 -2.413 .021
3 15.500 7.591 .000 1.00
1=Mastic, 2=Arabic, 3=Sugar (chewing gum), df =38, Sig<0.005

J Bagh College Dentistry Vol. 24(2), 2012 Dynamic lip to tooth
Dynamic lip to tooth relationship during speech, posed and

spontaneous smile using digital videography
Ali S. Al-khafaji, B.D.S. (1)
Nagham M. Al-Mothaffar, B.D.S., M.Sc. (2)
ABSTARCT
Background: The human face is a living mirror held out to the world. Natural, marked, painted or adorned, it has
power to attract, charm, captivate or brighten. Therefore the subject of the smile and facial animation, as they
relate to communication and expression of emotion, should be of great interest to orthodontists so the aims of this
study were to determine the difference of outer commissure width, inter-labial gap, smile index, modified smile index,
visible maxillary interdental width, buccal corridor percentage and maximum incisor show among different smile
styles (Monalisa, Cuspid and complex) during emotion, posed smile and speech. And to determine the differences of
the same variables for each smile style among emotional smile, posed smile and speech.
Materials and methods: The sample consisted of 77 Iraqi adult subjects (18-30) years with skeletal class I occlusion,
classified into three categories according to a certain neuromuscular mechanism of smile called smile style, the first
group consisted of 34 (24 male, 10 female) subjects with Monalisa smile style, the second consisted of 34 (22 male, 12
female) subjects with Cuspid smile style, the last 9 subjects (5 male, 4 female) were the third group with Complex
smile style. Each subject was recorded using digital videographic camera while watching a comical movie to elicit
emotional smile, then they asked to say “Chelsea eats cheesecake” to record them during speech. The videographs
were imported to the PMB-picture motion browser to capture emotional smile, posed smile and speech frames. Four
linear measurements were measured for each frame using AutoCAD program 2011.
Results: The results of this study showed that all the variables changed significantly when the subject change from
speech to emotional smile frame in all smile styles. And these changes revealed almost the same behavior when the
subject changed from speech to pose or to emotional smile frames.
Conclusion: The result of this study revealed that emotional smile is largely different from posed smile in different
aspects which has an effect on decisions related to orthodontic diagnosis and treatment plan.
Keywords: smile style, emotional smile, posed smile, digital videography. (J Bagh Coll Dentistry 2012;24(2):99-103).
INTRODUCTION
Obtaining a beautiful smile is always the main The unposed, spontaneous, enjoyment or real
objective of any aesthetic dental treatment. smile is involuntary and represents the emotion
Therefore, it is essential to control the esthetic that persons are experiencing at that moment.
effects caused by orthodontic treatment, which is Therefore it has many descriptions, such as
only possible by knowing the principles that laughing, cry, knowing or insipid (9). It is dynamic
manage the balance between teeth and soft tissues in the sense that it bursts forth but is not
during smile (1); as the presence of a malocclusion sustained.Emotional backgrounds influence a
has a negative impact on facial attractiveness and voluntary posed smile (10), A well-known
orthodontic correction of a malocclusion affects phenomenon in clinical practice is that patients
overall facial esthetics positively (2). After all, it is guard their smiles because of dissatisfaction with
the beauty of the smile that will make the them. When asked for a posed smile, they show
difference between an acceptable or pleasing only what they consciously or subconsciously
aesthetic result for any given treatment (3).Smiles want to present (11).Another example of interfering
can be either posed or spontaneous (4), the posed, emotional factors on the posed smile is feelings of
false, or social smile which is voluntarysmile and shame by victims of undisclosed childhood sexual
does not need an emotion to be accomplished. A abuse. Their social smiles appeared to be
posed smile is static in the sense that it can be considerably less expressive; sospontaneous
sustained (5). When posing for a photograph a smiling is a logical focus point in smile
person uses the social smile in social setting (6). In diagnostics (12). This is in line with
treating the smile, the social smile generally recommendations of oral surgeons and esthetic
represents a repeatable smile (7). However, the dentists (13) .Smile style is another soft-tissue
social smile can mature and might not be determinant of the dynamic display zone. There
consistent over time in some patients (8). are three styles: the cuspid smile, the complex
smile, and the Mona Lisa smile. An individual’s
smile style depends on the direction of elevation
(1) M.Sc. student, dep. of Orthodontics, college of dentistry, and depression of the lips and the predominant
university of Baghdad muscle groups involved. The cuspid or
(2) Professor, dep. of Orthodontics, college of dentistry,
university of Baghdad commissure smile is characterized by the action of
all the elevators of the upper lip, raising it like a To prompt emotional smiling, the subjects
window shade to expose the teeth and gingival watched television fragments of practical jokes
scaffold. The complex or full-denture smile is downloaded from the website of videos “you
characterized by the action of the elevators of the tube” the funniest Iraqi practical jokes. The
upper lip and the depressors of the lower lip subjects will be unaware of the exact aim of the
acting simultaneously, raising the upper lip like a study. While watching the television, the subjects
window shade and lowering the lower lip like a wear glasses with a clipped-on reference standard
window. The Mona Lisa smile is characterized by to enable calibration in a digital measurement
the action of the zygomaticus major muscles, program. In this way, a maximum emotional smile
drawing the outer commissures outward and (emotional smile frame) will be recorded with
upward, followed by a gradual elevation of the minimal intrusion of the subject (16).By using the
upper lip. Patients with complex smiles tend to same technique for obtaining natural head
display more teeth and gingiva than patients with position in emotional smile capture, the subject
Mona Lisa smiles (14). was asked to read a sentence appeared on the
screen made by a power point slide, this sentence
MATERIALS AND METHODS was “Chelsea eats cheesecake” to capture him\her
The sample of the study composed of 77 Iraqi saying the syllable “chee” (speech frame). The
adult subjects in an age group of 18-30 years with subject was asked to relax, and then smile to
skeletal class I occlusion.The sample was capture the posed smile (posed smile
classified into three groups according to smile frame).Firstly, the videographs were imported to
style as the following:Monalisa group composed the PMB- picture motion browser. This software
of 34 subjects (24 male and 10 female), Complex enables the operator to save a movie as an image
group composed of 9 subjects (5 male and 4 sequence and then export roughly 24 frames per
female), Cuspid group composed of 34 subjects second. Each frame could be saved identical in
(22 male and 12 female).This classification was size and resolution (17).To extract frame from
done depending on the direction of elevationand video recording of speech, a video converter
depression of the lips and the predominant muscle computer software was used to split the second in
groups involved.The video recordings for each which the subject saying the syllable “chee” in the
group were made in a setup consisting of a chair word “cheesecake” into 30 frames or more in
with a digital video camera and television set persons who pronounced the word very fast.In
(laptop connected to the screen). The television addition to high quality video recording mode
screen was placed at eye level. When the visual (HQ MODE) the photos (frames) extracted from
axis will be horizontal, the subjects will keep their the video clips were treated with another software
heads mainly in a natural head position(15). The which was the “photozoom pro 3” to improve
video camera was adjusted to the subject’s mouth image quality while zooming in AutoCAD
level at a 55-cm distance and continuously program 2011. Finally, smile frame was imported
registering the face as shown in figure 1. to the AutoCAD program. Magnification
correction was done in reference to the glasses
with the attached ruler, so that the real
measurements were obtained. After that,
landmarks were identified and measurements
were determined (Figure 2).
Figure 1: Standardization of the videogragh

Figure 2: Linear measurements during
emotional smile
RESULTS
The sample is classified into three groups, each Finally maximum incisor show (MIS) was only
group captured in three frames: speech, posed and significantly higher in Cuspid group than
emotional smile frames.Comparison among Complex group, but insignificantly higher in
different smile styles for each frame is done first, Monalisa than Complex group.
to compare among different smile style during The same method is used to compare among
emotional smile,analysis of variance (ANOVA different smile styles in speech and posed smile
test) was performed to identify the presence of frames. Comparison among different frames for
significant differences for the measured variables. each smile style is also done by ANOVA test for
As shown below (Table 1) there was a significant Monalisa group in different frames (emotional,
difference in all the variables measured except for posed, and speech frame) as revealed in Table 3.
outer commissure width.
Table 3: ANOVA test for Monalisa group in
Table 1: ANOVA test for emotional smile different frames
among different smile style. Variable F p-value Sig
Variable F p-value Sig OCW 20.94 .000 ***
OCW 0.320 0.727 Ns ILG 45.87 .000 ***
ILG 12.45 .000 *** SI 11.88 .000 ***
SI 13.90 .000 *** MSI 12.65 .000 ***
MSI 12.47 .000 *** VIW 80.08 .000 ***
VIW 21.66 .000 *** BCP 32.68 .000 ***
BCP 30.89 .000 *** MIS 30.89 .000 ***
MIS 3.657 0.03 **
The LSD test revealed that all variables shows
The LSD test (Table 2) was used to detect significant difference between every two frames
statistically significant difference between every except for smile index (SI) and modified smile
two groups for the significant different variable index (MSI) between posed smile and speech
found in ANOVA test (Table 1), Interlabial gap which were insignificantly differ from each other.
(ILG) and modified smile index (MSI) were Again the same statistical analysis is used to
significantly higher in Cuspid group when compare the other smile styles (Cuspid and
compared with Monalisa and Complex groups, Complex) in different frames.
while smile index (SI), visible intermaxillary
width (VIW) and buccal corridor percentage DISCUSSION
(BCP) was significantly higher in Monalisa and The age of the sample ranged from 18 to 30 years
Complex groups than in Cuspid group. because adolescents undergo a maturational
sequence in learning how to smile (18) and on the
Table 2: LSD for emotional smile frame other hand all dynamic measurements of the smile
among different smile style decrease with age especially after ages 30 to 39
Var. SMILE STYLE P SIG years (19). In addition in this study, there was no
Monalisa Cuspid .000 *** need to differentiate between genders (16). Firstly,
ILG Monalisa Complex .635 NS Emotional smile in each smile style:the Interlabial
Cuspid Complex .009 * gap (ILG) was significantly higher in Cuspid
Monalisa Cuspid .000 *** group than Monalisa and Complex groups, this
SI Monalisa Complex .846 NS increase may be due to the dominance of the
Cuspid Complex .003 ** levatorlabiisuperioris musclein Cuspid group
Monalisa Cuspid .000 *** exposing more attached gingivae above the
MSI Monalisa Complex .894 NS maxillary anterior teeth than the other groups and
Cuspid Complex .002 ** thus increasing Interlabial gap this comes in
Monalisa Cuspid .000 *** agreement with the explanation of Phillips in
VIW Monalisa Complex .465 NS 1999.The same reason mentioned above was
Cuspid Complex .000 *** responsible for significant increase in modified
Monalisa Cuspid .000 ***
smile index (MSI) and decreased smile index (SI)
BCP Monalisa Complex .946 NS
for Cuspid group over the other groups because
Cuspid Complex .000 ***
they depend on Interlabial gap (ILG). This come
Monalisa Cuspid .052 NS
in agreement with Ackerman and Ackerman
MIS Monalisa Complex .273 NS
(2002); Sarver and Ackerman (2003b) who found
Cuspid Complex .020 *
any increase in interlabial gap leads to decrease in significant reduction in inter-commissure distance
smile index and any increase in outer commissure (smile width) of posed smiling compared to
width leads to increase smile index. emotional smiling.The statistical significant
For visible maxillary interdental width (VIW) of increase of interlabial gap (ILG) of emotional
Complex group showed statistical significant smile over posed one may result from mouth
increase from Cuspid and statistical non- opening and increase in the mandibular anterior
significant increase from Monalisa groups, this tooth display during emotional smile.The
may be due to the fact that in Complex group the statistical significant decrease of interlabial gap
shape of the lips are typically illustrated as two (ILG) of speech when compared with posed smile
parallel chevrons, the levators of the upper lip, the comes in disagreement with Ackerman et al. in
levators of the corners of the mouth, and the 2004 who found insignificant increase of
depressors of the lower lip contract Interlabial gap (ILG) of speech when compared
simultaneously, showing all the upper and lower with posed smile.The statistical significant
teeth concurrently showing more area of upper increase of visible maxillary interdental width
teeth than the other groups, this comes in line with (VIW) of emotional smile when compared with
the conclusion Phillips 1999.For buccal corridor other frames may be as a result of exposing the
percentage (BCP) the same explanation can be 2nd premolar and 1st molar during emotional
given to significant increase of Complex group smiling than during posed smiling.
compared with Cuspid group because buccal The result of this study revealed that emotional
corridor percentage (BCP) depends on visible smile is largely different from posed smile in
maxillary interdental width (VIW).Finally the different aspects which has an effect on decisions
Cuspid group showed significant increase in related to orthodontic diagnosis and treatment
maximum incisor show (MIS) than Complex plan.The outer commissure width and visible
group, also may be due to that the vertical maxillary interdental width that compose the
distance between upper left central incisor incisal buccal corridor percentage, as we know the
edge and upper lip margin increased, this comes smaller the buccal corridor the greater the esthetic
in agreement with the findings of Phillips in appearance, and in posed smile the buccal
1999(20), who reported that the maximum incisor corridor is significantly lower than in emotional
show increased in Cuspid group. smile, so the dependence on buccal corridor
Speech in each smile style had a different lip- percentage (BCP) of posed smile can lead to
tooth characteristics, Although the main muscle inadequate diagnosis and treatment plan regarding
responsible for the morphological change in lips arch width, smile arc and transversal occlusal
during saying “cheese” is the orbicularis oris plane.This comes in agreement with Van der Geld
muscle, it may be affected by the specific et al., in 2008who stated that as a result of
neuromuscular mechanism of each smile style reduced smile width during posed smiling, the
because the levatorlabiisuperiorus muscle have buccal corridors can be underestimated and upper
the medial slip inserted into the orbicularis oris arch widening not deemed to be needed during
muscle(21). Also in a study of electromyography orthodontic or surgical treatment.The maximum
(EMG) of human lip muscle done by Blair and incisor show was significantly higher in emotional
Smith (22), they found that even with intramuscular smile than posed, in another words the lip line
electrodes, the probability of recording from a height is appeared too low in posed smile
single muscle of the lip during speech is particularly in the case of gummy smile patients,
extremely low. So the interaction of muscle of who have the muscular ability to raise the upper
facial expression during speech could explain why lip significantly higher than average on smiling
even with speech each smile style have different emotionally. Again it was the posed smile smaller
lip-tooth relationships.The explanations of measurement that may give us the errors in
significant increase or decrease of different estimation of gummy smile, and subsequently
variable during speech among different smile decisions of intrusion of maxillary anterior teeth
styles may resemble those of emotional or posed versus surgical intervention to correct the problem
smile patterns probably because of interfering becomes a matter of controversy.
facial muscle as discussed above.
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J Bagh College Dentistry Vol. 24(2), 2012 Dental caries in
Dental caries in relation to oral infections and feeding

types among children aged 2-5 years
Aseel H. M.J. Al-Assadi, B.D.S., M.Sc. (1)
ABSTRACT
Background: Dental caries is an infectious and transmissible disease that still represents as a significant public health
problems in many countries. The aim of this study was to investigate the relation between dental caries and oral
infections (tonsillitis and candidiasis) as well as the relation to feeding type.
Material and methods: The study sample composed of 22 healthy children aged 2-5 years with full set of primary
dentition and had dental caries. The control group composed of 22 caries free children matching the study group in
age and gender. An information sheet from the parents was done to all children concerning general health, feeding
habits and frequency of oral infections (tonsillitis and oral thrush) during the last year. Children were examined
clinically using dmft index, oral microorganisms was sampled and cultured aerobically using blood agar, MacConkey
agar, chocolate agar and sabauraud,s dextrose agar.
Results: Children with dental caries were mostly bottle fed and showed higher frequency of continuous oral
infections. Regarding dental caries there were highly significant relations between caries activity and method of
feeding and types of microorganisms found in the oral cavity , also a highly significant relation was found between
method of feeding and frequency of oral infections. Children with dental caries had more types of oral
microorganisms compared to caries free children Candida, Strep.pyogenes, Strep. viridans, Strep.faecalis,
Strep.pneumonia, Staph.aureus, E.coli, Enterobacter ,Acinetobacter and Pseudomonas were found in high
frequency among caries active children.
Conclusion: Types of microorganisms found in the oral cavity was affected by dental caries which in turn affect
frequency of infections. Breast feeding was predominant among caries free children and associated with lower rates
of oral infections compared with bottle feeding so public should informed about its long term effect on the general
health.
Keywords: Dental caries, tonsillitis, candidal infections, breast feeding. (J Bagh Coll Dentistry 2012;24(2):104-108).
INTRODUCTION The most important factor in the determination

Dental caries is one of the most prevalent of child medical and dental health is the family.
chronic disease(1) commonly affect children(2),it This may be due to the fact that family, especially
still holds the highest prevalence and severity the mother, greatly influences the health related
among other dental problems. The caries process behavior of the child (11,12). Most of mothers had
can develop as soon as the tooth erupted in the very little knowledge on how important breast
oral cavity(3).It is regarded as an infectious, milk is for a child’s health and, till now, the
contagious and multifactorial disease produced by delivery of formula milk is expected to replace the
three primary individual factors: cariogenic role of breast milk providing nutrition for infants
microorganisms, cariogenic substrate and which contains very high sugar and low on other
susceptible host (or tooth)(4). These factors nutrition elements (3). Concerning infants feeding
interact in a certain period of time causing an methods, prolonged and exclusive breast-feeding
imbalance in the demineralization and has been associated with many health benefits,
remineralization between tooth surface and the including reduced risks of gastrointestinal and
adjacent plaque (5). respiratory infection, atopic eczema and other
The oral cavity of neonates is germ free or allergic diseases, and improved neurocognitive
contains the same microorganisms of the vagina, development(13), while bottle fed children are
which will decrease in number few days after more prone to frequent infections such as oral
birth and will be readily changed by child thrush, acute otitis media and upper respiratory
caretaker microorganisms(6) . Thus the cariogenic tract infections(14).There are many studies found
microorganisms can be transmitted to the infant that bottle fed children are more likely to develop
and caries development may be favored (7), that dental caries than their breast fed counterparts (15-
18)
transmission may be vertical transmission from ,but others found no significant relation(8,19) .
caregiver to child and the major reservoir from Oral health is one component of general health
which infants acquire those microorganisms is and is an important factor in the normal
their mothers (8,9) or the horizontal transmission development of a child. Oral health problems or
(between members of a group e.g. family illnesses can influence the general development of
members of a similar age or students in a a child and its general health and can adversely
classroom) (10). affect quality of life (20).
(1)Lecturer, Department of Pedodontics and Preventive Dentistry, However, there is no available previous Iraqi
College of Dentistry, University of Baghdad study concerning the relation between dental

caries and oral infections. So this study was an Statistical analyses were performed using
attempt to determine this relation according to SPSS package version 16. Student’s t-test was
feeding habits and types of microorganisms found applied for comparisons between the caries free
in the oral cavity among group of children aged 2- and caries active group. (P < 0.05) was considered
5 year old. statistically significant.
MATERIAL AND METHODS RESULTS

Twenty two children with no history of any Children affected by tonsillitis continuously
systemic diseases aged 2-5 years were were more among caries active children (75%),
participated in the present study (study group). All while those affected by tonsillitis occasionally
of them were with full set of primary dentition were (68.75%) caries free. There was no
and had dental caries. The control group association between caries activity and frequency
composed of 22 caries free children matching the of tonsillitis. Concerning candidal infection,
study group in age and gender. A consent form children affected continuously were more among
obtained from the parents and an information caries active children 77.78%, while those
sheet filled by interview with them concerning affected few and distant times with candidiasis
general health, feeding habits and frequency of were more among caries free children 70.83%
oral infections (tonsillitis and oral thrush) of their (Table 1). Significant association was found
children. Exclusion criteria were antibiotic and ⁄or between caries activity and frequency of candidal
antimycotic treatment in the previous three infections (X2=9.217, P<0.01).
months at least and the presence of chronic There are 13 different types of microorganisms
disease, then the children were examined among caries active children, while in those with
clinically using WHO criteria and the index caries free children there were only 10 different
recorded as dmft (21). types of microorganisms (Table 2). In caries
Microbiological samples were obtained from active children, the highest percentage was
children by swapping their mucosal surface of the appeared to be found for Strept.viridans,
cheek, hard palate, dorsum of the tongue and floor Moraxella, Candida, Strep. Pyogenes ( 100%,
of the mouth with sterile cotton swap (22) .All 95.45%, 86.36% and 72.73% respectively),
these swaps cultured aerobically. Each swap however, in caries free children the highest
streaked on blood agar, MacConkey agar, percentage was appeared to be found for
chocolate agar and sabauraud,s dextrose agar then Strept.viridans and Moraxella, followed by
incubated aerobically for 24 hours at 370 C(23) . Staph. Epidermidis and then Candida. Highly
The morphology of different types of colonies significant association was found between caries
was recorded and smears of these different activity and types of microorganisms (X2=33.364,
colonies were done to study the Gram's reaction P<0.01).
and microscopical characteristic (24). A comparison between caries active and caries
Different types of colonies were sub cultured free children by method of feeding was shown in
and stored for further biochemical tests to reach Table 3, it was found that most of caries active
complete identification of each isolate. These tests children were fed by bottle feeding method
include: - (72.73%), while those with caries free were fed by
1. Hemolysis on blood and choclate agar plates breast feeding method(72.73%). Statistically,
(25)
. there was an association between caries activity
2. Differential and selective culture media: and method of feeding.
MacConkey's agar to observe lactose and non Table(4) reveals that only (8.33%) breast fed
– lactose fermenter colonies (Oxoid, England), children and (83.33%) bottle fed children were
Sabauraud's dextrose agar (Difco, USA) and affected continuously by tonsillitis; continuous
Mannitol salt agar to observe mannitol infection was more among bottle fed children than
fermenter colonies (Difco, USA). breast fed children. On the other hand, all those
3. Catalase test(24). with continuous candidal infections were feeding
4. Oxidase test. by bottle feeding method, while neither the breast
5. Slide Coagulase test(26). nor the mixed fed children were affected
6. Imvic(24) continuously by candidiasis. Highly significant
7. Urease test (24) . association was found between feeding method
8. Kliger iron agar (KIA) test (27). and frequency of infections regarding tonsillitis
9. Bacitracin differentiation test (28). and candidiasis (P<0.01).
10. Optochin sensitivity test (27).

DISCUSSION found in less frequency in caries free children

Although oral infections are usually not life which is in agreement with Nolte(35) who reported
threatening, it should be remembered that oral that these microorganisms are not commonly
health is one of the most important part of the found in the oral cavity. On the other hand, Sterp.
general body health. It is well documented that pyogenes isolates represents (72.73%) in caries
dental caries is the most prevalent oral disease active children, this higher percentage may be due
among children and young adults(29) and also it is to a positive correlation which was found between
considered as a public health problem(30). the presence of Strep.pyogenes in oral cavity of
According to some studies(31,32,33) the immune children and dental caries (35), and this is true
system of the oral cavity and the regulation the concerning the present study and this higher
oral microflora is considered as very important in percentage can support the higher frequency of
caries pathogenesis and that formation of immune continuous tonsillitis among caries active
system of the oral cavity to a great extent depend children, this was in agreement with Kipiani study
(33)
on the regional lymphoid organs and main role .
belongs to laryngeal and pharyngeal tonsils, In the present study, caries active children
(Tonsils are considered as lymphoid organs, were mostly fed by bottle feeding method,
providing oral cavity by immunoglobulins in however, breast feeding was the predominant
cooperation with salivary glands, consequently it feeding method among caries free children and
is supposed that tonsils play an essential role in this was similar to previous studies (3,15-18) this
suppression of cariogenic microflora, thereby could be due to the fact that human breast milk
providing caries prophylaxis or vice versa) (34). have buffer capacity that eventually able to
The percentage of caries active children affected prevent caries (3,9) and it contains caries protective
by tonsillitis and candidiasis continuously was elements such as maternal immunoglobulin’s,
higher than that of caries free children and this enzymes, leucocytes and specific antibacterial
could be due to the significant changes in the oral agents (40-42) , in addition to that cariogenic
ecosystem that was detected between the caries bacteria may not be able to utilize lactose as an
active and caries free children that may attributed energy source as readily as sucrose (43) and
to the difference between the two groups. Streptococcus mutans is highly susceptible to the
Present microbial investigations has shown bactericidal action of lactoferrin (which is found
that the predominant bacterial isolates which had in the breast milk) that chelates iron, making this
been found in both caries active and caries free essential nutrient inaccessible to an invading
children were Strep.viridans and Moraxella. microorganisms (44).
These two microorganisms are normal flora in the So as a conclusion, oral infections (tonsillitis
mouth and the presence of Moraxella in this high and candidiasis) are frequently occur among
percentage is in agreement with other studies children with dental caries, therefore, health
(16,35)
. education for parents and children to improve
The correlation between high prevalence of their knowledge concerning the effects of dental
candidal species in dental plaque and saliva and caries and oral infections should be planned and
the development of active caries lesions is carried out skillfully throughout specified
supported by many studies( 34,36,37,38) ,as well as the community health programs. Young nursing
present study that showed the next most common mothers should be advised and encouraged about
microbial isolates among caries active children the beneficial effects of breast feeding for the
was Candida (86.36%) compared to (9.09%) in child’s health since that it contains a lot of high
caries free children and this can explain the higher quality nutrition to enhance the immune system,
frequency of continuous candidal infections also contains other elements that have protective
among caries active children. Strep.pyogenes is a effects against caries process, while bottle feeding
β-haemolytic, it is one of the commonest bacterial contain very high sugar and low on other nutrition
pathogens that cause pharyngotonsilitis all over elements, if it is delivered in a wrong way it can
the world (39). In the present study, Strep.pyogenes caused caries.

Table 1: Frequency of oral infection occurrence among caries active and caries free children
Variables Frequency of infection Caries active Caries free Total X2
Continuously 9(75.00%) 3(25.00%) 12
Tonsillitis Occasionally 5(31.25%) 11(68.75%) 16 N.S.
Few and distant times 8(50.00%) 8(50%) 16
Continuously 7(77.78%) 2(22.22%) 9
Candidal
Occasionally 8(72.73%) 3(27.27%) 11 9.217 *
infection
Few and distant times 7(29.16%) 17(70.83%) 24
*Highly significant, P<0.01, df = 2
Table 2: Distribution of caries active and caries free children according to the types of micro-
organisms
Type of
Caries active Caries free X2
micro-organisms
Strep.viridans 22 22
Strep.faecalis 14 1
Strep.pyogen 16 1
Strep.pneumonia 1 0
Moraxella 21 22
Candida 19 2
Staph.aureus 6 1 33.364*
Staph.epi. 15 7
E.coli 6 1
Acinetobacter 5 2
Enterobacter 3 0
Pseudomonas 1 0
Klebsiella 1 1
*Highly significant, P<0.01, df=12
Table 3: Distribution of caries active and caries free children according to methods of feeding
Feeding method Caries active Caries free X2
Breast feeding 1 (4.55%) 16(72.73%)
Bottle feeding 16(72.73%) 2 (9.09%) 24.235*
Mixed feeding 5(22.73%) 4(18.18%)
Total 22 22
*Highly significant, P < 0.01, df= 2
Table 4: Occurrence of oral infections by method of feeding

Variables Frequency of infection Breast feeding Bottle feeding Mixed feeding Total X2
Continuously 1(8.33%) 10(83.33%) 1(8.33%) 12
Tonsillitis Occasionally 9(56.25%) 2(12.50%) 5(31.25%) 16 14.523*
Few and distant times 7(43.75%) 6(37.50%) 3(18.75%) 16
Continuously 0(0.00%) 9(100.00%) 0(0.00%) 9
Candidal
Occasionally 4(36.36%) 6(54.54%) 1(9.09%) 11 22.388*
infection
Few and distant times 13(54.17%) 3(12.50%) 8(33.33%) 24
*Highly significant, P < 0.01,df = 4
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J Bagh College Dentistry Vol. 24(2), 2012 The staining effect
The staining effect of chlorhexidine mouthwash on non

metallic brackets (An in vitro comparative study)
(1)
Hayder J. Attar, B.D.S., M.Sc.
Fakhri A. Ali, B.D.S., M.Sc. (2)
ABSTRACT
Background: Since it is needed to have means other than mechanical plaque control to achieve good oral hygiene
in orthodontic patients, and since an eliminating the metallic appearance of orthodontic appliance is always
desired to achieve a maximum esthetic appliance, so this study was done to investigate and compare the staining
effects of chlorhexidine mouthwash 0.2% on the un bonded ceramic brackets, ceramic brackets bonded with no
mix adhesive, ceramic brackets bonded with light cured adhesive, un bonded composite brackets, composite
brackets bonded with no mix adhesive and composite brackets bonded with light cured adhesive.
Materials and Methods: The effect of the chlorhexidine was studied through immersion the brackets and bonded
brackets in the mouth wash for three different time intervals: 1, 2 and 3 hours, which represent the accumulated daily
use of the mouthwash for 1, 2, and 3 months respectively and compared them with corresponding control groups
which not immersed in chlorhexidine 0.2%. The sample consisted of two hundred eighty eight brackets. AShimadzu,
UV 160A UV-Visible spectrophotometer was used to perform a light absorption test for each subgroup with twelve
brackets each.
Results: ANOVA and LSD post Hoc tests were used to identify the significant effects of the mouthwash at a
significance level P ≤ 0.05, ِA significant effects identified with ceramic brackets bonded with no mix adhesive,
ceramic brackets bonded with light cured adhesive, un bonded composite brackets, composite brackets bonded
with no mix adhesive and composite brackets bonded with light cured adhesive, while non significant effect of un
bonded ceramic brackets.
Conclusions: It can be concluded that the chlorhexidine mouthwash do not have a staining effect on the un
bonded ceramic brackets while significant changes in staining effect when ceramic and composite brackets
bonded to no mix adhesives and that effect decrease when bonded to light cured adhesives. The mouthwash has a
staining effect on the un bonded composite brackets also.
Key words: Ceramic bracket, composite bracket, chlorhexidine. (J Bagh Coll Dentistry 2012;24(2):109-113).
INTRODUCTION
The esthetic requirements of orthodontic when internal structure is penetrated by a
treatment prompted the development of tooth- discoloring agent; according to his definition; the
colored brackets as alternatives to metal brackets term staining and discoloration were used
(1)
. Many types of nonmetallic brackets fabricated synonymously. However; extrinsic staining
from alumina and zirconia ceramics, as well as a defined as staining that could be easily removed
variety of plastic brackets and composite brackets by normal prophylactic cleaning, intrinsic staining
had been introduced during the past decades (2) was defined as endogenous discoloration that had
Some of the earliest applications of chlorhexidine been incorporated in to the structure matrix and
for the control of plaque and gingivitis go back to thus could not be removed by prophylaxis (8). The
1970s, when the dental literature reported on the etiology of the dental discoloration is
use of 0.2% chlorhexidine gluconate rinses; twice multifactorial in which different part of the tooth
a day; to prevent plaque accumulation and could take up different stains (9).
subsequent gingivitis (3). The adequate plaque Mouth wash containing chlorhexidine caused
control was difficult in patients undergoing superficial black and brown staining of the teeth
(10, 11)
orthodontic treatment, especially in the cases of . Ceramic brackets are more esthetic than
children and adolescents and when bands and metal brackets, and unlike plastic or composite
auxiliaries were involved (4). Many researchers brackets, they resisted staining and discoloration
(12)
classified staining as either extrinsic or intrinsic (5,
6)
.There was confusion concerning the exact Orthodontic adhesives could have intrinsic and
definitions of these terms. Feinman et al (7) extrinsic discoloration, chlorhexidine could
described extrinsic discoloration as occurring discolor composite extrinsically and with time
when an agent stains or damage the enamel become intrinsically throughout a resin matrix,
surface of teeth and intrinsic staining as occurring which was usually attributable to chemical
(1)M.Sc. student, Department of Orthodontics, College of degeneration of the filler–resin bond and
Dentistry, University of Baghdad. solubility of the resin matrix (13).
(2)Professor, Department of Orthodontics, College of Dentistry,
University of Baghdad

MATERIALS AND METHOD adhesive was removed from around the

Two types of brackets were used in this study, bracket base with a sharp scalar (Bishara et al,
they were of standard edgewise (22×30 slot 2005)
dimension), and with horizontal grooves in the • The visible light-cured adhesive specimens
base of bracket to generate a macro-retention were photopolymerized with a light-curing
undercuts to achieve maximum mechanical unit (YDL/ Hangzhou Yinya Co.,China); the
bonding surface. They include: light guide of curing light unit was directed
Reflections® ceramic brackets which was made toward the bracket, the light shined through
from 99.9% pure polycrystalline alumina, Rave® the bracket for 20 second (according to
composite brackets were made from Injection manufacturer instruction .(The bonded
Molded High Quality Reinforced Composite to brackets were allowed to bench set for 24 hr to
increase bracket body strength with precise slot ensure complete polymerization of adhesive
dimensions(Ortho Technology/U.S.A.( material, then after setting; the celluloid strips
Resilience® No-Mix orthodontic adhesive, were removed and the resultant bracket-
Resilience Primer®, Resilience® Light-Cure bonded adhesive were flat.
orthodontic adhesive, Resilience light cure Immersion in chlorhexidine:
Primer®(OrthoTechnology/U.S.A.) were used for Un bonded and bonded brackets were farther
bonding . subdivided according to time interval immersion
Corsodyl® Chlorhexidine digluconate 0.2% W\V, in chlorhexidine 0.2% into four groups with 12
(GlaxoSmithKline, UK) was used as a test brackets each which include 1 hour,2 hours ,3
immersion media in the study. hours immersion in chlorhexidine and one control
Bonding procedure: group which not immersed in chlorhexidine. Then
The sample composed of 144 Reflections® the immersion procedure was done by positioned
ceramic brackets and 144 Rave® composite each bracket on a black rectangular cardboard
brackets, the brackets were divided according to (35×45×0.2 mm) with central window, the
bond material into three groups of 48 brackets: cardboards were numbered and using the number
• Un bonded brackets which were not bonded to of the card as a reference .The specimens then
any bond materials. immersed in Chlorhexidine 0.2% solution
• Chemically cured bonded brackets in which contained in inert plastic containers. Immersion
the brackets were bonded using chemically was done according to the different time intervals
cured adhesive resin. for one, two, and three hours in Chlorhexidine
• Light cured bonded brackets in which the gluconate mouth rinse 0.2% at 37˚с in the
brackets were bonded using light cured incubator
adhesive resin. Assessment of staining :
The ceramic and composite brackets were The samples were taken out of the immersion
bonded with a chemically cured, light-cured media; then Staining measurements were
orthodontic adhesive as follow: performed over the 800 to 200 ŋm visible
• Resilience Primer® was applied by brush on wavelength range with UV-Visible
each bracket base or Resilience light cure spectrophotometer (Shimadzu; UV160A; Japan.(
Primer® used with Resilience® Light-Cure The chamber of the spectrophotometer was
orthodontic adhesive . opened, and then the black rectangular cardboard
• A small amount of the adhesive paste was with bracket positioned in central window was
applied onto the bracket base, and then by used to position the bracket in the front part of the
using a clamping tweezer the bracket was analytical beam holder of spectrophotometer,
placed lightly onto a horizontal flat plastic Then the chamber was closed and the machine
plate mounted on the table of surveyor(Dent was given the order to start scanning starting from
aurum, Germany) covered by a celluloid strip 800ŋm wavelength in the infra-red zone to 200ŋm
to facilitate detachment of the bracket– wavelength in the UV zone passing through the
adhesive complex with a recovery of the set entire visible spectrum .
material. The light passes through the sample; then the
• A constant load of two hundred grams was intensity of the remaining light was measured
placed on the bracket to ensure a uniform with a light sensor, the results appeared as a graph
thickness of the adhesive, the load fixed to the from which the amount of light absorption was
upper part of the vertical arm of the surveyor, plotted and the amount of absorbed light at a
a surveyor rod was fixed in the lower part of 345ŋm wavelength visible light was obtained and
the vertical arm of the surveyor and put it in used in the later statistical analysis .
contact with the bonded bracket, excess

Statistical analysis composite bracket bonded with chemically cured

Descriptive statistics: including mean, standard orthodontic adhesive (No mix) group and the
deviation, and standard error. Inferential statistics: composite bracket bonded with light cured
including: One way analysis of variance orthodontic adhesive group
(ANOVA) to test any statistically significant LSD test for the Un bonded composite bracket
difference among the light absorption of groups group revealed a statistical significant difference
and Least significant difference (LSD)to test any between the control and 1 immersion hours,
statistically significant differences between each control and 2 immersion hours, control vs. 3
two subgroups when ANOVA showed a statistical immersion hours and when comparing 1 hour vs.
significant difference within the same group. 2hours and comparing 1 hour vs. 3 hours; while a
Significance for all statistical tests was non significant difference when comparing 2
predetermined at P≤ .05. hours vs. 3 hours.
LSD test for the composite bracket bonded with
RESULTS chemically cured orthodontic adhesive (No mix)
The staining effect of chlorhexidine 0.2%- group revealed a statistical significant difference
Effect of time: for all pair comparisons. LSD test for the
Generally, for most groups the amount of light composite bracket bonded with light cured
absorption increase as time of immersion in the orthodontic adhesive group revealed a statistical
chlorhexidine increase. But, in un bonded ceramic significant difference between the control and 1
brackets group the readings of light absorption in immersion hours, control and 2 immersion hours,
control and after 1, 2 and 3 immersion hours in control vs. 3 immersion hours, and when
the chlorhexidine 0.2% was not changed, the peak comparing 1 hour vs. 2hours and comparing 1
reading in the immersion 3hours reading. hour vs. 3 hours; while a non significant
Ceramic bracket group (Table 1 and Fig. 1) difference when comparing 2 hours vs. 3 hours.
The Un bonded Ceramic bracket group showed a The staining effect of chlorhexidine 0.2%-
statistical non-significant difference among Effect of adhesives:
reading of control, 1, 2 and 3 immersion hours in For both the ceramic and composite bracket
Chlorhexidine 0.2% by ANOVA test . groups; the peak light absorption appear in
The ceramic bracket bonded with chemically brackets bonded with no mix then the readings
cured orthodontic adhesive group (No mix) and decreased in brackets bonded with light cure and
The ceramic bracket bonded with light cured the least reading of light absorption was in Un
orthodontic adhesive group showed statistical bonded brackets for the same time interval in
significant difference among readings of control, 1, 2 and 3 hours of immersion in the
control,1, 2 and 3 immersion hours in chlorhexidine 0.2% .
chlorhexidine 0.2% by ANOVA test. LSD test for When comparing the amount of light absorption
the ceramic bracket bonded with chemically cured by ceramic and composite brackets bonded with
orthodontic adhesive group (No mix) revealed a different adhesives at the same time interval by
statistical significant difference when comparing ANOVA test a statistical significant difference
the control vs. 1 hours; a high significant was found (p<0.001) among brackets bonded with
difference when comparing the control vs. 2 hours no mix, brackets bonded with light cure and Un
and control vs. 3 hours; non significant difference bonded brackets. LSD test appeared that a
when comparing 1 hour vs. 2hours; while a high significant difference found when comparing Un
significant difference when comparing 1 hour vs. bonded brackets vs. brackets bonded with no mix,
3 hours and 2 hours vs. 3 hours . un bonded brackets vs. brackets bonded with light
LSD test for the ceramic bracket bonded with cure and when comparing brackets bonded with
light cured orthodontic adhesive group revealed a no mix vs. brackets bonded with light cure.
non significant difference when comparing
control vs. 1hours; a significant difference when DISCUSSION
comparing control vs. 2hours, and control vs. The Un bonded Ceramic brackets was made from
3hours, a highly significant difference in LSD test Aluminum oxide which is an inert material due to
when comparing 1 hour vs. 2 hours, 1 hour vs. 3 the crystalline structure of ceramic; as a result, it
hours and 2 hours vs. 3 hours. cannot chemically interact to any of the
Composite bracket group (Table 1, Fig. 1) chlorhexidine molecules; also the glazed surface
One way ANOVA test showed a statistical of the bracket reduce the overall surface
significant difference among reading of control, 1, roughness and the adsorption of chlorhexidine on
2 and 3 immersion hours in chlorhexidine 0.2% bracket surface. (Table 1, Fig. 1)
for the Un bonded composite bracket group, the

chemically cured orthodontic adhesive (No mix) greatly, thus a statistical significant difference
when bonded to ceramic brackets might affect the among readings of control, 1, 2 and 3 immersion
staining resistance of ceramic brackets or the hours showed in ANOVA test, and the significant
significant difference might due to staining of difference for all pair comparisons in LSD test(
orthodontic adhesive alone . Figure-1).
One of factors that affects light absorption values The light cured orthodontic adhesive bonded with
is the time so that when time of immersion composite bracket present a non homogenous
increased; the adsorption of water molecules profile due to oxygen inhibition at the surface
(physisorption) increased, water is a softener of during polymerization. Oxygen causes
plastics and increases the deterioration of the resin deactivation of the free radicals and reacts with
matrix, and therefore water-soluble chlorhexidine the photo initiator, which decreases curing
0.2% could penetrate the composite causing efficiency of the oxygen-rich surface layers of the
chemical degeneration of the filler–resin bond and material, the oxygen-rich surface layers could
solubility of the resin matrix, chlorhexidine also hydroxylated by water absorption form negative
contain 15% of alcohol; which increase the ionic layer that interact with positive cationic
monomer release from composite and increase the group of chlorhexidine which increases the
surface degradation of adhesive; produce rough deterioration of the resin matrix causing increase
surface which increase the chlorhexidine in light absorption reading so a statistical
deposition but this degradation effect might difference among readings of control, 1, 2 and 3
require time so the non significant difference was immersion hours in ANOVA test and a statistical
found in LSD test when comparing 1 hour vs. 2 significant difference between all pair
hours in ceramic + no mix group (Figure 1) comparisons except when comparing 2 hours vs. 3
when ceramic brackets bonded with light cured hours in which a non significant difference
orthodontic adhesive; the bonded adhesive might revealed in LSD test, that because the degradation
affect the staining resistance of ceramic brackets might be somewhat retarded due to the saturation
which explain the statistical significant difference of composite and the adhesive resin by
among reading of control, 1, 2 and 3 immersion chlorhexidine and the reaction reached an
hours in ANOVA test(Figure 1); or the significant electrostatic balance.
difference might due to the ‘‘incomplete From this study we can conclude that:
polymerization’’ phenomenon of light cure 1. Un bonded Ceramic brackets were not affected
adhesive which occur due to number of factors by staining of chlorhexidine mouth wash
that affect the depth of photo activated cures, 0.2%.
including factors of illumination from the edges of 2. Ceramic and composite brackets bonded with
bracket and critical total transmittance value of no mix orthodontic adhesive affected by
bracket in which duration and intensity of light staining of chlorhexidine 0.2% slightly during
exposure may be attenuated by the bracket the first time of exposed to chlorhexidine then
structure, incomplete polymerization increase the staining increase significantly with time.
monomer leaching and cause alteration in light 3. Ceramic brackets bonded with light cured
absorption values indicating a decreased color orthodontic adhesive affected by staining of
stability of light cure composite. chlorhexidine 0.2% less than ceramic brackets
Chlorhexidine infusion to Un bonded composite bonded with no mix orthodontic adhesive.
bracket during immersion caused degradation of 4. Un bonded composite brackets and Composite
composite bracket, swelling of composite, fissures brackets bonded with light cured orthodontic
and cracks formation, a drastic reduction of the adhesive affected by staining of chlorhexidine
polymer's molecular weight and lead to 0.2% and this effect become limited with time.
discoloration. The degradation might be 5. Chemically cured orthodontic adhesive were
somewhat retarded because the saturation of affected by staining effect of chlorhexidine
composite bracket by chlorhexidine. So a non 0.2% more than light cure orthodontic
significant difference when comparing 2 hours vs. adhesive; when it was bonded to ceramic or
3 hours in LSD tests. (Figure 1) composite brackets .
The presence of no mix in composite bracket
bonded with chemically cured orthodontic REFEERENCES
adhesive might provide additive effect by 1. Swartz ML. Ceramic brackets. J Glin Orthod 1988;22:
increasing the bulk of material that interact with 82-88.
chlorhexidine (bracket composite and adhesive 2. Eliades Theodore, George Eliades, Brantley, and
composite); Also the intensity of light passes Johnston: Orthodontic Materials: scientific and clinical
through the bulk of the resin material decreases aspects.2nd ed.: Thieme, Stuttgart, Germany
2001.P.557-647, 77-82.

3. Löe H., Schiött CR, Glavind L., Karring T. Two years 9. Eriksen HM, Nordbo H, Kantanin H. Chemical plaque
oral use of chlorhexidine in man. J Periodont Res control and extrinsic tooth discoloration, A review of
1976; 11:135-44. possible mechanisims. J Clin Periodont 1985; 12: 245-
4. Lundström F, Hampton SE. Effect of oral hygiene 50.
education on children with and without subsequent 10. Leard A, Addy M. The propensity of different brands
orthodontic treatment. Scand J Dent Res 1980;88:53- of tea and cafee to cause staining associated with
9. chlorhexidine. J Clin Period 1997; 24:115-118
5. Dayan D, Hiefferman A, Goreski M,Beigleiter A. 11. Eley BM,Antibacterial agents in the control of
Tooth discoloration-extrinsic and intrinsic factors. supragingival plaque. Br Dent J 1999;186:286-96.
Quintessence Int 12(14)1983: 1-5. 12. Meguro D, Hayakawa T, Kawasaki M, Kasai K. Shear
6. Hayas PA, Full C, Pingham J. The etiology bond strength of calcium phosphate ceramic brackets
andtreatment of intrinsic discolorations. J Clin Dent to humen enamel. Angle Orthod 2006; 76(2): 301-5 .
Asso1986: 217-20. 13. Matasa CG. Resin-based composites. Today For half a
7. Feinman RA,Goldstein RE, Garber DA. Bleaching century, little progress: however, “nanos” are behind
teeth.1st ed.Quintessence:1987:188-195. the corner! The orthodontic materials insider 2005;
8. Teo CS. Management of tooth discolorations. Acta 17(3).
Med Singapore; 1989. p 585-90.
Table 1: Descriptive statistics of the amount of light absorption by different bracket groups at
different time interval of immersion in chlorhexidine 0.2%
Un bonded Brackets Bracket +no mix Bracket +Light cure
Brackets Time N
Mean SD SE Mean SD SE Mean SD SE
control 12 2.072 0.007 0.002 2.315 0.005 0.001 2.224 0.008 0.002
1 HR 12 2.072 0.007 0.002 2.325 0.010 0.003 2.232 0.005 0.001
Ceramic
2 HR 12 2.072 0.007 0.002 2.332 0.020 0.005 2.252 0.020 0.005
3 HR 12 2.073 0.007 0.002 2.350 0.005 0.001 2.274 0.010 0.003
control 12 2.042 0.002 0.000 2.261 0.004 0.010 2.245 0.014 0.004
1 HR 12 2.131 0.005 0.001 2.355 0.011 0.003 2.280 0.005 0.001
Composite
2 HR 12 2.254 0.005 0.001 2.428 0.006 0.001 2.347 0.008 0.002
3 HR 12 2.256 0.008 0.002 2.447 0.005 0.001 2.348 0.004 0.001
Figure 1: the amount of light absorption of ceramic and composite bracket

groups at different time interval of immersion in chlorhexidine 0.2%

J Bagh College Dentistry Vol. 24(2), 2012 Tooth attrition patterns
Tooth attrition patterns in a group of Iraqi adults sample

with different classes of malocclusion
(A comparative study)
Issam M. Abdullah, B.D.S. (1)
Ausama A. Al- Mulla, B.D.S., Dr.D.Sc. (2)
ABSTRACT
Background: Tooth attrition is wearing away of tooth structure during mastication. This study investigated tooth wear
patterns in adults with different classes of malocclusion and compared them with normal occlusion.
Materials and methods: The sample consisted of 363 subjects that were divided into 5 groups with an age range “18-
25” years: 85 normal occlusion, 128 class I with crowding, 90 class II division 1, 30 class II division 2 and 30 class III.
Dental wear was assessed by using a modified version of the tooth wear index.
Results:
1. The class I malocclusion group had statistically greater tooth wear in incisal surfaces of maxillary central and lateral
incisors, and mandibular lateral incisors than did the normal occlusion.
2. The class II division 1 group had statistically greater tooth wear in the occlusal surfaces of maxillary second
premolars, mandibular first and second premolars. Buccal surfaces of mandibular canines, mandibular second
premolars and mandibular first molars than did the normal occlusion.
3. The class II division 2 malocclusion group had statistically greater tooth wear in labial surfaces of mandibular
central and lateral incisors. Buccal surfaces of mandibular second premolars, mandibular first molars. Occlusal
surfaces of maxillary first and second premolars and mandibular second premolars than did normal occlusion.
4. The class III malocclusion group had statistically greater tooth wear in the occlusal surfaces of maxillary first and
second premolars than did normal occlusion.
Conclusion: In conclusion subjects with normal occlusion and those with different classes of malocclusions have
different tooth wear patterns.
Keywords: attrition, wear patterns, modified tooth wear index. (J Bagh Coll Dentistry 2012;24(2):114-119).
INTRODUCTION it does not take into account teeth that were

Due to the decreasing occurrence of dental restored due to wear (8). The modifications
caries in many societies, increasing attention has matched the World Health Organization
focused on tooth wear from erosion, abrasion and standards, thus allowing application of the index
attrition (1). Tooth wear is a normal physiologic in broad epidemiologic surveys for both of
process that occurs through a variety of deciduous and permanent dentitions (9). Some
mechanisms and increases with age. It can be studies indicate that masticatory forces and
defined as the noncarious loss of tooth substance malocclusion are primary etiologic factors for
as a result of the combined processes of erosion, noncarious lesion development (10-14), although
attrition, and abrasion; these terms reflect specific other authors did not find this correlation (15-18).
etiologic factors (2). Gradual attrition of the Because of the high prevalence of malocclusions
occlusal surfaces of the teeth appears to be a as well as the controversies in the studies of tooth
general physiologic phenomenon in all mammals, wear, it is relevant to verify the pattern of tooth
in every civilization, and at all ages. Tooth wear wear of various occlusal relationships to help
has characteristic features that must be professionals to differentiate between physiologic
distinguished from abrasion and erosion and and pathologic processes.
characterized as flat, sharply or round angled and
polished surfaces and may come from excessive MATERIALS AND METHODS
attrition of one tooth against the other (3) .Smith The sample has been selected randomly from
and Knight (4) introduced the tooth wear index the students of Babylon university (college of
(TWI), which attempted to provide a solution to medicine, college of dentistry and college of
some problems associated with measuring wear at nursing) and some patients were selected
the individual and community levels. The TWI randomly from the patients attended the
and modified versions of it have been used in orthodontic department and oral medicine
many studies; this suggests widespread department of dentistry college of Babylon
acceptance (5-7). However, it was described as University. Out of 440 persons only 363 subjects
flawed when used in an aging population, because were selected (18-25 years old) and divided into
(1) MSc. Student, Department of Orthodontics, College of five groups:
Dentistry, Baghdad University. 1. Group one included 85 subjects with normal
(2) Professor, Department of Orthodontics, College of Dentistry,
Baghdad University. occlusion (45 males and 40 females).

2. Group two included 128 subjects with class 2. Class II division 1:

I malocclusion with crowding (63 males and The normal occlusion group had statistically
65 females). greater tooth wear in the incisal surface of
3. Group three included 90 subjects with class maxillary lateral incisors incisal surface of
II division 1 malocclusion (35 males and 55 mandibular central incisors and incisal surface of
females). maxillary canine than did the class II division 1
4. Group four included 30 subjects with class malocclusion group, (table 3). The class II
II division 2 malocclusion (12 males and 18 division 1 group had statically greater tooth wear
females). in the occlusal surfaces of maxillary second
5. Croup five included 30 subjects with class premolars, occlusal surfaces of mandibular first
III malocclusion (14 males and 16 females). premolars , occlusal surfaces of mandibular
The sample was taken in terms of the following second premolars (table 3), labial surfaces of
criteria:- mandibular canines, buccal surfaces of
1. The sample was all of Iraqi Arab in origin. mandibular second premolars and buccal surfaces
2. No previous orthodontic treatment. of mandibular first molars than did the normal
3. No extracted teeth up to the first molar. occlusion group, (table 3)
4. No openbite. 3. Class II division 2:
5. No parafunctional habits. The normal occlusion group had statistically
6. No temporomandibular joint problems. greater tooth wear in the incisal surface of
The surfaces of all teeth in the mouth were maxillary lateral and incisal surfaces of
scored according to tooth wear index by Smith maxillary canines than did class II division 2
and Knight (4) modified by Sales Peres et al.(7). group, (table 4). The class II division 2
The modifications matched the World Health malocclusion group had statically greater tooth
Organization standards (9), thus allowing wear in labial surfaces of mandibular central
application of the index in broad epidemiologic incisors, labial surfaces of mandibular lateral
surveys for both of deciduous and permanent incisors, buccal surfaces of mandibular second
dentitions. The modifications made calibration premolars, buccal surfaces of mandibular first
easier because the modified tooth wear index does molars, occlusal surfaces of maxillary first
not differentiate the depth of dentin involvement, premolars, occlusal surface of maxillary second
as does the original tooth wear index. premolars, and occlusal surfaces of mandibular
In addition, the modified version includes a second premolars than did normal occlusion
code for teeth that have been restored due to wear group, (table 4).
(code 4) and another code for teeth that cannot be 4. Class III:
assessed (code 9); the amount of permanent tooth The normal occlusion group had statistically
wear is scored by numbers (Table 1). Each 2 groups greater tooth wear in the incisal surface of
were compared using Mann Whitney test for the maxillary central incisors, incisal surface of
frequency and severity of wear on each surface of maxillary lateral incisors, incisal surface of
each group of teeth. maxillary canines, incisal surfaces of mandibular
central incisors, incisal surfaces of mandibular
RESULTS lateral incisors, incisal surfaces of mandibular
In total, 17424 dental surfaces were evaluated. Of canines, palatal surfaces of maxillary central
these, 64.2 % had no dental wear (score 0), 33.8% incisors, palatal surface of maxillary lateral
had incipient lesions (score 1), 1.3 % had incisor, palatal surface of maxillary canines,
moderate lesions (score 2) and 0.7% were occlusal surfaces of mandibular first molars and
excluded (score 9).No severe lesions were found. buccal surfaces of mandibular first molars than
1. Class I (crowding): did class III group, (tables 5). The class III
The class I malocclusion group had statistically malocclusion group had statistically greater tooth
greater tooth wear in incisal surfaces of maxillary wear in the occlusal surfaces of maxillary first
central incisors, incisal surfaces of maxillary premolars and surfaces of maxillary second
lateral Incisors and incisal surfaces of mandibular premolars than did normal occlusion group, table
lateral incisors ( table 2) than did the normal (table 5).
occlusion.
The normal occlusion group had statistically DISCUSSION
greater tooth wear in the incisal surfaces of The results of this study showed that the
maxillary canines and Buccal surfaces of normal occlusion patients and those with class I
mandibular first (tables 2), than did the class I malocclusion (crowding), class II division 1, class
malocclusion (crowding). II division 2 and class III had some tooth wear.

However, the groups had different tooth wear with Oltramari et al. (24) and this may be due to
patterns, Tables (2-5). size and age of sample.
1. Class I malocclusion (crowding) Class II Division 1 malocclusion group showed
The normal occlusion group differs from class I greater tooth wear on the posterior teeth (table 3),
with crowding in that the normal occlusion tooth this may be due to two factors. One is the large
wear was greater on the incisal surfaces of the overjet that increases the likelihood of
maxillary canines, compared with the interferences of the posterior teeth during
corresponding surfaces of the malocclusion protrusion until the incisors make contact as the
group(table 2), this probably occurred because of mandible is advanced (19, 25). The other is that,
the normal anteroposterior relationship, because the canines are not in a favorable position
establishing immediate lateral guidance during to disclude the posterior teeth, these take the role
lateral mandibular excursions (19). Since these of the canines during lateral mandibular
teeth disclude the posterior teeth during lateral excursions and are therefore subjected to greater
mandibular functional movements, it seems wear.
logical that they have greater wear, this finding 3. Class II division 2 malocclusion
came to be in agreement with Janson et al.2010 In the normal occlusion group, tooth wear was
(23)
and Oltramari et al. 2010 (24). As a result of greater on the incisal surfaces of the maxillary
unfavorable positioning of the canines in class I lateral incisors and the maxillary canines,
crowding as in many cases of class I coming with compared with the corresponding surfaces of class
buccally malposed canines these teeth also do not II division 2 malocclusion group (table 4). Less
disclude the posterior teeth as frequently as in wear on the incisal surfaces of the maxillary
normal occlusion, because of interferences of the lateral incisors in the Class II malocclusion group
posterior teeth (19, 25). Thus, there is less wear on presumably is a consequence of the labial
the incisal surfaces of the maxillary canines in the positioning of these teeth in this type of
class I group. malocclusion, which also is characterized by
Thus, there is less wear on the incisal surfaces of uprighted central incisors, deep overbite, and
the maxillary canines in the class I group. The normal overjet (26-29) .With this interocclusal
buccal surfaces of mandibular first molars had arrangement, disclusion on protrusion is carried
tooth wear more than the class I malocclusion out primarily by the maxillary central incisors
(crowding), this may be due to the subjects with with occasional contact of the lateral incisors.
crowding had narrower arches than the normal Greater tooth wear on the incisal surfaces of the
occlusion (20, 21) so the maxillary first molars did canines in the normal occlusion group, probably
not probably overlap the mandibular molars. occurred because of the normal anteroposterior
Thus, there is less wear in the buccal surface of relationship, establishing immediate lateral
mandibular first molar because all of the wear guidance during lateral mandibular excursions (19,
located in areas of occlusal contact (22). The more 25)
. In comparison with normal occlusion, subjects
tooth wear in incisal surfaces of maxillary and with class II division 2 had greater wear on the
mandibular incisors in class I crowding subjects labial surfaces of mandibular incisors and this
may be due to irregularities and disarrangement of may be due to this type of malocclusion
these teeth, table. characterized by uprighted central incisors, deep
2. Class II division 1 malocclusion overbite, and normal overjet (26-29) , thus during
In the normal occlusion group, tooth wear was protrusion subjected to greater tooth wear.
greater on the incisal surfaces of the maxillary Subjects with Class II Division 2 malocclusion
lateral incisors and canines and mandibular had greater wear on the posterior teeth (occlusal
central incisors compared with the II division 1 surface of maxillary first and second premolars
malocclusion (table 3). Greater tooth wear in the and mandibular second premolar and buccal
anterior region in the normal occlusion group surfaces of maxillary second premolar and first
probably occurred because of normal vertical and molar), a difference that was statistically
horizontal anterior tooth relationships, significant compared with that of the normal
establishing immediate anterior and lateral occlusion sample, and this may be because the
guidance during protrusion and lateral mandibular canines are not in a favorable position to
excursions, respectively (19, 25). As we mentioned disocclude the posterior teeth during lateral
above these teeth disclude the posterior teeth excursions in class II division 2 malocclusion, the
during mandibular functional movements, so it posterior teeth assume this role and consequently
will have greater wear, this finding came to be in have greater wear than observed in the normal
agreement Janson et al. (23) and partial agreement occlusion group. This occlusal configuration
occurs because of the broad, square-shaped

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in and polarization of dental caries occurrence among its relationship to tooth size and arch dimension. Am J
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Update 1989; 16:204-12. R. Jakobsen. Arch widths in adults with class I
3. Cunha Cruz J, Pashova H, Packard JD, Zhou L, Hilton crowded and class III malocclusions compared with
TJ for Northwest Precedent. Tooth wear: prevalence normal occlusions. Angle Orthod 2008; 78(4): 597-
and associated factors in general practice patients. 603.
Community Dent Oral Epidemiol 2010; 38: 228–34.

22. Spear F. A patient with severe wear on the anterior 29. Brezniak N, Arad A, Heller M, Dinbar A, Dinte
teeth and minimal wear on the posterior teeth. J Am A,Wasserstein A. Pathognomonic cephalometric
Dent Assoc 2008; 139:1399-403. characteristics of Angle Class II Division 2
23. Janson G, Oltramari-Navarro P, de Oliveira R, malocclusion. Angle Orthod 2002; 72:251-7.
Quaglio CL, Sales- Peres SH, Tompson B. Tooth-wear 30. Guyer EC, Ellis EE III, McNamara JA Jr, Behrents RG.
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malocclusion and normal occlusion. Am J Orthod adolescents. Angle Orthod 1986; 56: 7-30.
Dentofacial Orthop 2010; 137: 14.e1-14.e7. 31. Mohammed Taher Bukhary. Comparative
24. Oltramari-Navarro, Janson, Salles de Oliveira. Tooth- cephalometric study of class III malocclusion in Saudi
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25. Roth RH, Rolfs DA. Functional occlusion for the characteristics of sample Saudi female adults with class III
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Table 1: Criteria used for the measurement of tooth wear, according to the modified tooth wear
index
Permanent
teeth Criteria Description
scores
0 Normal _ no evidence of wear No loss of surface features
Loss of enamel giving a smooth glazed shiny appearance,
1 Incipient _ tooth wear into enamel
dentine is not involved
Extensive loss of enamel with dentine involvement.
2 Moderate tooth wear into dentine
Exposure of dentine
Severe _ tooth wear into pulp or Extensive loss of enamel and dentine with secondary dentine
3
secondary dentin. or pulp exposure
Restored _tooth wear leading to
4 The tooth received restorative treatment due to tooth wear
restoration
Extensive caries, large restoration, fractured tooth and
9 Could not be assessed
missing tooth,
Table 2: Intergroup tooth wear comparisons, normal occlusion and class I malocclusion
(Mann-Whitney test)
Class I malocclusion
Normal occlusion
tooth (crowding) P
Mean of scores SD Mean of scores SD
Incisal/ occlusal surface
Maxillary teeth
Centrals 0.729 0.521 0.867 0.341 0.01*
Laterals 0.552 0.5 0.781 0.415 0.00*
Canines 0.776 0.542 0.539 0.613 0.002*
Mandibular teeth
Lateral /right 0.765 0.427 0.898 0.303 0.01*
Labial surfaces
Mandibular teeth
First molars 0.2 0.402 0 0 0.001*
*Statistically significant at P < 0.05

Table 3: Intergroup tooth wear comparisons, normal occlusion and class II division 1(Mann-
Whitney test)
Normal occlusion Class II division 1
tooth P
Maxillary teeth
Laterals 0.529 0.526 0.366 0.484 0.04*
Canines 0.776 0.542 0.533 0.622 0.003*
Second premolars 0.176 0.383 0.288 0.456 0.01*
Mandibular teeth
Centrals 0.859 0.515 0.7 0.507 0.04*
First premolars 0.294 0.458 0.5 0.503 0.006*
Palatal surfaces
Maxillary teeth
Centrals 0.471 0.547 0.444 0.499 0.86
Labial/ buccal surfaces
Mandibular Teeth
Canines 0.071 0.258 0.167 0.375 0.049*
First molars 0.2 0.402 0.489 0.489 0.001*
Table 4: Intergroup tooth wear comparisons, normal occlusion and class II division 2 (Mann-
Whitney test)
Normal
Class II division 2
tooth occlusion P
Maxillary teeth
Laterals 0.529 0.526 0.233 0.43 0.007*
Canines 0.776 0.542 0.2 0.407 0.005*
First premolars 0.388 0.537 0.633 0.615 0.045*
Mandibular teeth
Labial surfaces
Mandibular teeth
Centrals 0.059 0.237 0.2 0.407 0.024*
Laterals 0.024 0.152 0.2 0.406 0.001*
First molars 0.188 0.393 0.5 0.508 0.001*

J Bagh College Dentistry Vol. 24(2), 2012 Clinical significance of sella
Clinical significance of sella turcica morphologies and

dimensions in relation to different skeletal patterns and
skeletal maturity assessment
Kasim A. Obayis, B.D.S. (1)
Ali I. Al-Bustani, B.D.S., M.Sc. (2)
ABSTRACT
Background: Sella turcica is a saddle-like structure based on the roof of the sphenoid bone and has an important
role in orthodontic diagnosis and treatment planning. The aims of the study were to assess sella shape and size in an
adolescent Iraqi sample in different skeletal classes and to verify the possibility of clinical application of sella turcica
in skeletal maturity estimation.
Materials and Methods: The study sample composed of (140) Iraqi adolescent subjects aged 10-16 years (91 females,
49 males); every subject had true lateral cephalometric radiograph. The sample was subjected to 2 classifications:
the 1st included three skeletal classes according to ANB angle, and the 2nd included accelerative and decelerative
groups according to maturity indicators of cervical vertebrae seen radiographically. In each classification, sella size
was measured using three linear measurements (S.length, S.depth, and S. diameter).
Results: Most of sella turcica measurements were not different statistically among the skeletal classes, and that
specific sella turcica linear measurements can not be obtained for each specific skeletal class throughout the
pubertal period. Normal sella was the predominant over the other morphological aberrations in both classification
systems, while these morphologies occurred more frequently in class II and III. Sella depth and diameter were
significantly higher in the decelerative than accelerative group, while non significant difference was found
concerning sella shapes between the two groups.
Conclusions: It was concluded that Sella depth and sella diameter measurements can be utilized clinically for
pubertal growth phase determination, while sella morphology can not be diagnostic for the accelerative and
decelerative pubertal growth phases.
Keywords: Sella Turcica, Pubertal growth, Skeletal Maturity. (J Bagh Coll Dentistry 2012;24(2):120-126).
INTRODUCTION
Several landmarks within the cranium have been For this reason, it is very important to study the
determined to act as reference points when tracing effect of puberty (a period of significant body
cephalometric radiographs. These landmarks are changes) on the normal morphology of this
used to measure positions of structures (such as landmark clearly in a young sample, as it is
the maxilla or mandible) in relation to the studied in an adult sample, since this has a great
cranium, or to themselves. The benefits gained importance in orthodontic diagnosis and treatment
from studying these structures serve: in assisting planning.
the orthodontist during diagnosis, as a tool to Previously, when studying the sella turcica size
study growth, and in evaluation of orthodontic (length, depth and diameter) and its relation to
treatment results.(1) different skeletal patterns, no statistically
One of the most commonly used cranial significant correlation between facial type and the
landmarks for cephalometric tracing is sella point. mean sella turcica area of the pituitary fossa had
This point is located in the centre of the sella been presented.(9) However, Alkofide (1) when
turcica, with the turcica housing and protecting evaluated skeletal type and linear dimensions of
the pituitary gland in the cranial base.(2) sella turcica, a significant difference was found.
Any abnormality or pathology in the gland could When comparing skeletal class II and class III
manifest from an altered shape of the sella turcica subjects, a significant difference was observed
and/or a disturbance in the regulation of secretion between the diameter of the sella turcica in both
of glandular hormones. (3-6) The anatomy of the skeletal classes which may be attributed to
sella turcica has been described as being genetic factors.
variable.(7) Morphologically, three basic types— Although the morphology and dimensions of
oval, round, and flat—have been classified, the sella turcica have been studied by previous
oval and round types being the most common. researchers on adult Iraqi samples (10,11), until now
During embryological development, the sella no Iraqi study has been done to evaluate the linear
turcica area is a key point for the migration of the dimensions and morphological structure of sella
neural crest cells to the frontonasal and maxillary turcica in an adolescent Iraqi sample. Although
developmental fields.(8) no significant differences had been obtained
(1) M.Sc. Student, Department of Orthodontics, Dental College, between males and females in terms of mean
University of Baghdad. linear dimensions of the sella turcica, previous
(2) Assistant professor, Department of Orthodontics, Dental studies (1,12,13) found a significant effect of age on
College, University of Baghdad.
Orthodontics, Pedodontics, and Preventive Dentistry 120

sella turcica dimensions. So the present study was A) The length of the Sella Turcica: Was
the first Iraqi study that evaluated the linear measured as the distance from the Tuberculum
dimensions and morphological structure of sella Sellae (TS) to the tip of Dorsum Sellae (DS).
turcica in an adolescent Iraqi sample, and their B) The depth of Sella Turcica: Was measured as
relationship to different skeletal patterns. a perpendicular from the line mentioned above to
Furthermore, this study was (for the 1st time) the deepest point on the floor of the fossa (BPF).
attempted to test the possibility of clinical C) The anteroposterior greatest diameter of the
employment of Sella Turcica in pubertal growth Sella Turcica: Was measured from the
estimation. Tuberculum Sellae (TS) to the furthest point on
the posterior inner wall of the fossa (SP).
Shape of Sella Turcica
MATERIALS AND METHODS For the assessment of the morphological
The sample aberrations of the sella turcica (after enlargement
The sample of this study consisted of radiographs of its view), in addition to the normal morphology
for patients who were attending the preventive of sella turcica traced in (figure 2); the different
and orthodontic clinics at the teaching hospital of morphological appearances of the sella turcica
the College of Dentistry – Baghdad University described by Axelsson et al. (13,20) (figure 2), were
seeking paedodontic and orthodontic treatments. used to classify sella shapes in the current study.
The sample was all of Iraqi origin, with an age The six morphological variations that are rated as
ranging between 10-16 years. Out of 185 subjects normal included oblique anterior wall, sella
examined, only 140 subjects (49 males and 91 turcica bridging, double contour of the floor,
females) met the inclusion criteria including no irregularity (notching) in the posterior part of the
history of systemic disease (clinically healthy dorsum sellae, extremely low sella turcica, and
patient) or trauma in the craniofacial complex, no pyramidal shape of the dorsum sellae.
syndromes (clefts of the lips and palate), and no Skeletal Maturation Assessment
history of previous orthodontic treatment. Every The second part of the study has concerned with
subject has to be free from any congenital or verifying the possibility of using the sella turcica
acquired malformations of the cervical vertebrae for pubertal growth estimation by depending on a
(seen radiographically).(14) method of skeletal maturation assessment using
The sample has been subjected to two the Maturity Indicators of Cervical Vertebrae.
classification systems. 1st, according to ANB This method has been developed by Hassel and
angle (15-17) into skeletal class I (13 males, 38 Farman (14) (CVMI). They described certain
females), class II (20 males, 20 females), and criteria for assessing maturational changes on the
class III (16 males, 33 females). 2nd, according to second, third, and fourth cervical vertebrae, which
Maturity Indicators of Cervical Vertebrae (CVMI) can be visualized on the lateral cephalograms
(14)
into accelerative (56) and decelerative (43) even if a thyroid protective collar has been worn
groups respectively. during radiation exposure.
In the 2nd classification system, by excluding the The two skeletal stages (stages I and VI)
easily recognized skeletal (I and VI) stages at the represent the extremes of the pubertal growth
extremes of pubertal growth stages from the total period, which can be very easily diagnosed
radiographs, the total sample (140) became (99) clinically by the orthodontist. Greater efforts
radiograph. were, therefore, done to concentrate on subjects at
the skeletal stages which require certain maturity
METHOD indicators for their determination, specially
Cephalometric Analyses skeletal stages III and IV. For more facility and
All Lateral Cephalometric Images were analyzed practicality, the six pubertal growth stages have
by an AutoCAD program (version 2007) to been condensed only into two growth phases or
measure the ANB angle and to calculate the linear stages (accelerative and decelerative),i.e., by
measurements of Sella Turcica. excluding the two skeletal stages (stages I and VI)
Size of Sella Turcica at the extremes of the pubertal growth period, the
According to Silverman (18) and Kisling (19) the two accelerative (stages II and III) and the two
following lines were measured to determine the decelerative (stages IV and V) were combined to
size of the Sella Turcica, all the reference lines represent the accelerative and decelerative groups,
used were situated in the midsagittal plane (figure respectively. (14,21,22)
1): Furthermore, since males and females pass
during puberty through the same physiological
sequence,i.e., both progress towards skeletal

maturity with advancement of age and growth; years earlier than males, a significant change in
therefore, the total sample has been classified into pituitary fossa size occurs in females from 11 to
accelerative and decelerative groups without male 14 years of age. Thereafter, the late growth
and female classification. acceleration in males, which is usually about 2
Statistical Analysis years later than females, results in an approximate
The statistical analysis included: equalization in sella area in both genders.
I. Descriptive Statistics: Including (Mean value, On the other hand, by comparing sella
Standard deviation, Number and Percentage, and measurements among the skeletal classes, it was
Statistical tables). found that the sella depth was significantly higher
II. Inferential Statistics: Including (ANOVA test, in class I than in class II (table 1). This finding
LSD test, Independent t-test, and Likelihood Ratio may be attributed to genetically determined
test (Lx2)) growth factors. According to this study result,
specific sella turcica linear measurements can not
RESULTS AND DISCUSSION be obtained for each specific skeletal class
The literature involves different age ranges, with throughout the pubertal period.
the puberty may begin as early as 9 or 10 years, In comparison with adult studies Meyer-
and may end as late as 18 or 19 years of age. By Marcotty (6), Yassir et al. (10), and Al-Ani (11), it
selecting the 10-16 years age range, therefore, could be demonstrated that the length, depth, and
reconcilement of the different findings about the diameter of the sella turcica region of all
pubertal timing has been done. (22,23) Size examined patients in this study tended to be
measurements of the sella turcica have, to-date, smaller, a finding that confirms the effect of age
almost solely been used as a diagnostic tool on sella measurements.
concerning expanding tumors or tumor-like Investigations concerning the sella turcica have
processes in the pituitary gland. (1,24,25) not only focused on size, but also on morphology.
(1,2,6,10,11,13,20,29)
Statistically, there were non significant gender No previous studies concerning
differences in all sella turcica linear sella morphology have mentioned the gender
measurements (S. length, S. depth and S. difference in each skeletal class separately during
diameter) in skeletal class II and III, while the two pubertal period alone, rather previous studies have
measurements (S. depth and S. diameter) were either compared between males and females as a
significantly higher in females than in males total sample (Yassir et al.(10) and Axelsson et
dealing with skeletal class I (table 1). This may be al.(13,20)) or they compared between the classes (as
explained by: 1st, The explicit discrepancy in a total in each class) without giving gender
gender distribution in this skeletal pattern.2nd, The difference (Meyer-Marcotty et al.(6); Yassir et
earlier pubertal growth spurt in females which al.(10); Abdel-Kader (30)). Furthermore, these
may influence their sella measurements. studies used the frequency and percentage as a
Genetic factors most likely play a leading role in baseline for comparison, i.e. descriptive statistics
male-female growth differences. The marked only, and they did not use inferential statistical
advancement of girls over boys in the rate of analyses between genders and among the classes.
maturation is attributed to the delaying action of Normal sella turcica was the predominant shape
the Y chromosome in males. By delaying growth, over the other morphological variations in all
the Y chromosome allows males to grow over a skeletal classes (table 2). This predominance can
longer period of time than females, therefore be attributed to growth and development basis.
making possible greater overall growth. (26) Sella turcica is expected to become oval to more
On the other hand, non significant gender mean round (i.e. normal) with craniofacial growth
difference was found concerning the sella length progression. This is true if we follow the normal
in class I. This may be attributed to a greater growth and development of sella turcica, as it
pubertal growth influence on the vertical than on appears as a shallow-like depression at the fetal
the anteroposterior (Sella length) dimension. By stage, while as the growth of the cranium
comparing the subjects’ linear dimensions of sella proceeds it becomes slightly oval to round at the
turcica with normative data from the literature, the permanent dentition stage (at adolescence). This
former result was in agreement with Alkofide (1) result comes to be in agreement with (Alkofide (1);
and Yassir et al.(10), while the latter result was in Yassir et al.(10); Al-Ani (11) and Axelsson et
agreement with Silverman (18), Chilton et al.(27), al.(13,20)) their results showed that a normal sella
and Elster et al.(28) who revealed that the pituitary turcica morphology was seen in two-thirds of the
fossa of males tended to be larger than that of subjects, while the remainder showed
females during childhood. After that, due to the dysmorphological appearances.
pubertal growth spurt in females which begins 2

Any deviation from the above mentioned sella the mean values of sella (depth and diameter)
growth and development map can account for the between groups, respectively.
occurrence of these shapes. Statistically, only in This finding may be related to growth and age
class III, Likelihood Ratio test showed significant progression background. Bone apposition on the
difference between males and females for the anterior part of the interior surface of the sella
different shapes of sella turcica. Skeletal class III turcica is ceased at an early age, whereas
can be considered as a type of craniofacial resorption is continued for a long time on the
deviation in which growth pattern is abnormal. distal part of the sella floor and on the posterior
Furthermore, greater percentages of males are wall.(35-38) Furthermore, the anterior wall of the
affected by this type of malocclusion than sella turcica reaches stability at 5-6 years of age
females. So, if we consider morphological sellar and the tuberculum sella and the posterior wall of
aberrations as a deviation from the normal the sella turcica stop growing at ages of 18 years
development of sella turcica, abnormal sella may in males and 16 years in females (at the ends of
occur more frequently in this class and mostly in pubertal growth).(39) This can give us two
males. important findings. First, the reference point 'sella'
The predominance of non significant sella would, therefore, with growth and age
morphology differences between genders enabled progression, be displaced backwards and
dealing with the subjects as a total sample within downwards. Second, Sella depth and diameter
each skeletal class. Although multiple would be increased with age and at specific time
comparisons were made among the classes, a females are having higher sella measurements
significant difference only was present between than males.
class II and III (table 3). Genetically determined Related previous studies,(1,2,9,12,13,18,27,29,40) have
growth factors may have a role. Formation and dealt with the age factor, rather than pubertal
development of the sella turcica and dental growth spurt. They mostly confirmed two
structures share, in common, the involvement of findings: 1st, sella size increases significantly with
neural crest cells. In fact, the anterior part of the age; 2nd, sella depth and diameter are the most
sella turcica is believed to develop mainly from influenced linear measurements by the age factor
neural crest cells, (31,32) so any structural in comparison with sella length.
deviations in the anterior wall are believed to be According to this study result, sella depth and
associated with specific deviations in the facial sella diameter measurements can be utilized
skeleton.(33) Moreover, During embryological clinically for pubertal growth phase
development, the sella turcica area is a key point determination. This requires larger sample
for the migration of the neural crest cells to the collection so that cut-off points and intervals
frontonasal and maxillary developmental fields. (8) (ranges) can be estimated for the accelerative and
The majority of normal sella turcica appeared to decelerative stages.
be present in skeletal class I followed by class III
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than accelerative group. Statistically, there were J Orthodontics 2010; 3: 148-153].
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enlarged sella turcica on a lateral cephalogram.

Table 1: Descriptive and Inferential Statistics for Sella measurements in (mms).

Sella length Sella depth Sella diameter
sk. class
Sex n Mean SD P.value sex n Mean SD P.value sex n Mean SD P.value
♂ 13 6.94 1.8 ♂ 13 6.26 0.8 ♂ 13 9.11 1.57
.001** .006**
cl. I ♀ 38 6.54 1.33 .39 (NS) ♀ 38 7.52 1.25 ♀ 38 10.3 1.2
(HS) (HS)
total 51 6.64 1.46 total 51 7.2 1.27 total 51 10 1.39
♂ 20 7.08 1.69 ♂ 20 6.7 1.06 ♂ 20 9.5 1.33
0.7 0.36 0.48
cl. II ♀ 20 6.88 1.5 ♀ 20 6.34 1.37 ♀ 20 9.79 1.27
(NS) (NS) (NS)
total 40 6.98 1.58 total 40 6.52 1.22 total 40 9.64 1.29
♂ 16 6.64 2.08 ♂ 16 6.41 1.25 ♂ 16 9.17 1.57
0.3 0.26 0.1
cl. III ♀ 33 7.17 1.45 ♀ 33 6.9 1.47 ♀ 33 9.92 1.42
(NS) (NS) (NS)
total 49 6.99 1.67 total 49 6.74 1.41 total 49 9.68 1.5
ANOVA 0.46 (NS) ANOVA 0.041* ANOVA 0.37 (NS)
Class I- Class II Class I- Class III Class II- Class III
Variable
Mean difference P-value Mean difference P-value Mean difference P-value
Sella depth 0.68 0.015* 0.46 0.08 (NS) -0.22 0.44 (NS)
Table 2: Number distribution and percentage of Sella shape in skeletal classes with gender
difference.
Class I (n=51) Class II (n=40) Class III (n=49)
S. shape Male female male female male female
p-value p-value p-value
n % n % n % n % n % n %
Normal 7 53.80% 29 76.30% 13 65% 10 50% 7 43.75% 23 69.70%
0.194 0.429 0.035
Oblique 2 15.40% 1 2.60% 3 15% 2 10% 3 18.75% 1 3%
Bridge 3 23.10% 2 5.30% 3 15% 4 20% 3 18.75% 1 3%
significance
significance
significance
Notching 0 0.00% 2 5.30% 0 0.00% 2 10% 0 0.00% 0 0.00%
Double 0 0.00% 1 2.60% 0 0.00% 0 0.00% 0 0.00% 5 15.20%
Pyramidal 1 7.70% 3 7.90% 0 0.00% 1 5% 2 12.50% 2 6.10%
Low 0 0.00% 0 0.00% 1 5% 1 5% 1 6.25% 1 3%
Total 13 100% 38 100% NS 20 100% 20 100% NS 16 100% 33 100% S
Table 3: Number distribution and percentage of Sella shape for total sample with shape
difference among skeletal classes.
Skeletal class
Shape
Sella shape Class I Class II Class III C.S
difference
n % n % n %
Normal 36 70% 23 57.50% 30 61.20%
Oblique 3 5.90% 5 12.50% 4 8.20% Cl. I- II P-value 0.205 NS
Bridge 5 9.80% 7 17.50% 4 8.20%
Notching 2 3.90% 2 5.00% 0 0.00%
Cl. I- III P-value 0.162 NS
Double 1 2.00% 0 0.00% 5 10.20%
Pyramidal 4 7.80% 1 2.50% 4 8.20%
Low 0 0.00% 2 5.00% 2 4.00% Cl. II- III P-value 0.048* S
Total 51 100% 40 100% 49 100%
Table 4: Descriptive statistics of S. Turcica linear measurements for Pubertal growth stages
with mean difference statistics.
Mean difference Stage of growth
(d.f.=97) Decelerative(N=43) Accelerative(N=56) Variable
P-value t-value SD Mean Max. Min. SD Mean Max. Min.
0.682 Sella
0.41 1.4 6.81 9.86 4.29 1.53 6.93 11.46 4.39
(NS) length
.020* Sella
-2.365 1.37 7.32 9.78 3.8 1.34 6.67 9.66 3.43
(S) depth
.009** Sella
-2.677 1.16 10.4 14.08 7.03 1.25 9.74 13.96 7.26
(HS) diameter
NS = P> 0.05 Non significant. * = 0.05 ≥ P > 0.01 Significant. ** = P ≤ 0.01 highly significant.

SP
Figure 1: Normal sella turcica morphology and reference lines used for measuring sella size. TS,
tuberculum sella; DS, dorsum sella; BPF, base of the pituitary fossa; SP, sella posterior; white
line, length of sella; red line, diameter of sella; blue line, depth of sella.
Figure 2: Tracings and details from lateral cephalograms of the different morphological types
of sella turcica: (A) Double contour of the floor, (B) extremely low sella turcica, (C) Sella turcica
bridging, (D) Irregularity (notching) in the posterior part of the dorsum sellae (E) oblique
anterior wall and (F) Pyramidal shape of the dorsum sellae.

J Bagh College Dentistry Vol. 24(2), 2012 Clinical performance comparison
Clinical performance comparison of a clear advantage

series II durable retainer with different retainers' types
Mustafa M. Al-Khatieeb, B.D.S., M.Sc. (1)
ABSTRACT
Background: The orthodontic retainers are either fixed or removable. Each has its own advantages and
disadvantages. The goal of the current study was to evaluate the new Clear Advantage Series II durable thermo-
vacuum formed invisible orthodontic retainer material and compare the clinical performance of such retainer with
the most standard types of retainers (convention Clear Advantage Series I thermo-vacuum formed invisible retainer,
Hawley, and the fixed lingual bonded retainers). The conducted study is the first attempt to evaluate and compare
the clinical performance of different retainers' types.
Subjects and methods: Twenty finished fixed orthodontic patients starting the retention phase were divided into four
groups. Each group consisted of five patients (3 females and 2 males), mean age ranged 18-30 years old. Members
of the first group were given the new thermo-vacuum formed invisible Clear Advantage Series II durable retainer
material (CII), While the second, third, and fourth groups were given standard thermo-vacuum formed invisible Clear
Advantage Series I retainer material (CI), Hawley retainer (HR), and fixed lingual bonded retainers "cuspid to
cuspid"(FR), respectively. Ten variables were applied on the twenty patients to evaluate the clinical performance of
the four retainers' types, the ten variables were evaluated and judged by the operator with the patient as three non-
parametric categorical descriptions: superior (+), acceptable (±), and inferior (-) properties.
Results: It was found that patients were compliant with all types of retainers initially, and the compliance decreased
at a much faster rate with both types of themo-vacuum formed retainers (CII and CI) than with HR and FR retainers,
and patient's compliance is greater with HR and FR retainers than with CII and CI retainers. A comparison of the total
variables of the clinical performance at total time intervals using chi-square showed that there was a significant
difference (P<0.05) in the acceptable categorical description between CII and CI retainers and very high significant
difference (P<0.001) between CII, HR, and FR retainers.
Conclusion: it was found that the new thermo-vacuum formed Clear Advantage Series II durable retainer showed a
combination of removable, comfortable, aesthetic, better speech, superior retention, relatively not producing bad
taste and odor, hygienic, least soft tissue irritability, superior construction and chair-side time, and durable, it will be
more favorable clinical performance appliance to both the patient and the orthodontist.
Keywords: Clinical performance, Clear Advantage Series II Durable, Retainers. (J Bagh Coll Dentistry 2012;24(2):127-
136).
INTRODUCTION In addition, research has shown that alveolar bone

In orthodontics, although the patient may feel is laid down after one month and supracrestal
that treatment is complete when the appliances are fibers require one year to remodel, therefore,
removed, an important stage lies ahead, which is retention and relapse are considered as vital issues
the retention phase, retention has been defined by of a complete and a successful orthodontic
Moyers (1) as the process of maintaining the treatment (2). There are literatures on retention and
moved teeth into the new position long enough to post-treatment relapse, which have been reviewed
aid in stabilizing their correction. Relapse has in some depth (5-8).
been defined as a return of teeth to their original In orthodontic, there are grossly two types of
position or a shift in arch relationship after the orthodontic retainers: removable (commonly
end of treatment, because teeth tend to move back temporary), and fixed (commonly permanent) (9-
11)
to their pre-treatment positions if they are not . A temporary retainer is designed for a
retained (2-4). The etiology of relapse is relatively limited retention period to allow for the
multifactorial and can be divided into three main reorganization of the gingival & periodontal
areas: physiological recovery, unfavorable tissues (8). Henry Baker used maxillary and
growth, or "true relapse" due to the placement of mandibular vulcanite removable retainers with
the teeth in an unstable position (4). labial wires, but the vulcanite was not adapted to
Reitan (5) in 1967 showed that periodontal the teeth. Instead, the teeth were prevented from
ligament takes 232 days to reorganize and can moving lingually by metallic spurs embedded in
derotate teeth after one years. The periodontal the vulcanite (12). The retainers of Chartes A.
ligament requires three to four months' Hawley (13) in 1919 were an improvement over
masticatory stimulation for organization of its Baker's in that the base material was flowed
fibers. against the lingual surfaces, thus helping to
prevent rotations. In 1930s, vulcanite was
(1) Lecturer, Department of Orthodontics, Dental College, replaced by acrylic, and till now the orthodontists
University of Baghdad. are using the Hawley retainer and its many known
modification (12-14). The invisible retainers was

developed by Robert Pointz (15) in 1971, later on inch (OrthoTechnology-Tampa, Florida, USA),
Essix retainers were introduced by Sheridan et al Hawley retainer fabricated with polymethyl-
(16)
in 1993. Typically such invisible retainers are methacrylate "powder and liquid" (Orthocryl®,
formed from a sheet of thin Biocryl™, or other Dentaurum, Ispringen, Germany) and 0.7mm
similar material that is heated & formed by hard stain-less steel wire (Dentaurum, Ispringen,
suction or pressure on to a work model of the Germany), and fixed lingual bonded retainers
dentition (15-18). "cuspid to cuspid" with assorted sizes (Ortho
The purpose of the current study was to evaluate Matrix; USA) bonded with light activated
the new Clear Advantage Series II durable orthodontic bonding system (Resilience ®, Ortho
retainer and compare the clinical performance of Technology-Tampa, Florida; USA), respectively,
such retainer with the most standard types of the retainers' materials were shown in figure 1.
retainers (convention Clear Advantage Series I The Clear Advantage Series II thermo-vacuum
thermo-vacuum formed invisible retainer, formed durable invisible retainer, the Clear
Hawley, and the fixed lingual bonded retainers). Advantage Series I thermo-vacuum formed
standard invisible retainer, and the fixed bonded
lingual retainer were placed on the same day as
SUBJECTS AND METHODS the fixed appliances were removed, while the
Twenty finished fixed orthodontic patients Hawley retainers were placed one to seven days
attended a private clinic in Baghdad city, starting after the removal of the fixed appliances, the four
the retention phase were selected from 29 patients types of retainers were shown in figures 2 to 5.
after discussion the study with them from ethical Ten variables were applied on the twenty
approval point of view, and only those willing to patients to evaluate the clinical performance of the
provide complete co-operation were enrolled in four retainers' types, the ten variables were
the study and fully informed consents were taken, evaluated and judged by the operator with the
the twenty patients were divided into four groups. patient as three non-parametric categorical
Each group consisted of five patients (3 females descriptions: superior (+), acceptable (±), and
and 2 males), mean age ranged 18-30 years old. inferior (-) properties, these ten variables were.
Patient exclusion criteria: 1. Versatility: it indicates the adaptability and
1. Craniofacial anomalies, symptoms of tempero- comfort of the patient to the retainer.
mandibular joint disorders, history of 2. Aesthetic: It means the beauty and the
orthognathic surgery, or bad habits. invisibility of the retainer.
2. Unsatisfied patients to the final orthodontic 3. Speech: It indicates the effect of the retainer
fixed treatment objectives. on speech.
3. Unavailable patients for long term (1 year) 4. Retention: It indicates the stability of the
follow-up evaluation. retainer during rest and animation.
Methodology: The treatment protocol was as 5. Bad taste and odor: It refers if the retainer
follow: produces a bad taste and smell.
All participants were previously treated with 6. Caries risk: It refers to the hygienic property of
Roth system upper and lower fixed orthodontic the retainer.
appliances (Bracket's slot size 0.022", Pyramid 7. Soft tissue irritability: It refers to the ability of
Orhodontics, CA; USA). An alginate impressions the retainer to produce irritation to the soft
(Tropicalgin-normal setting Zhermack ®; Italy) tissue (gingival, lip, cheek, and tongue).
were taken by assorted sizes rim lock trays 8. Construction times: It refers to how much time
(Frontier Dental Industrial Co., China) for the does it need to construct the appliance till
patients' upper and lower dental arches then insertion inside the patient's mouth, noted as
poured with type four thixotropic die stone (Elite superior (short time), acceptable (intermediate
Stone - Zhermack; Italy) after considering the time), and inferior (long time).
manufacturer instructions. All retainers were 9. Chair-side time: It refers to how much time
fabricated by the same private laboratory. does it need to place, fit, or bond the retainer at
Members of the first group were given the new each visit, also it involves the time needed for
thermo-vacuum formed invisible Clear Advantage repairing the appliance.
Series II durable retainer material, thermal 10. Failure of retention material: It refers to the
forming coping polypropylene; 0.040 of an inch durability of the retainer's material inside the
(OrthoTechnology-Tampa, Florida; USA). While patient's mouth. Without crack, perforation,
the second, third, and fourth groups were given fracture, or debonding.
standard thermo-vacuum formed invisible Clear
Advantage Series I thermal forming
splint/copolyester retainer material; 0.040 of an
The clinical performance of the new Clear Australia, New Zealand, United States and United
Advantage Series II durable thermo-vacuum Kingdom to identify consistencies in retention
formed invisible retainer was evaluated at the time procedures and found that the most commonly
of retainer insertion, three months, six months, used retainers were invisible retainers (vacuum-
and one year post-insertion follow-up (19,20) in formed) and canine to canine bonded lingual
comparison with the three of the most standard retainers. Hawley retainers declined in use from
and commonly used retainers; convention Clear 1986 to 2011, whereas invisible retainers and
Advantage Series I thermo-vacuum formed fixed bonded canine to canine retainers increased
(25-28)
invisible retainer, Hawley, and the fixed lingual . Therefore, in the current study, the new
bonded retainers. retainer (Clear Advantage Series II durable
All patients received upper and lower retainers, retainer) was compared with the most commonly
the invisible retainers were full coverage type, and used retainers in orthodontics (standard thermo-
the patient should wear the removable retainer full vacuum formed invisible retainer, Hawley, and
day time (except during meals for thermo-vacuum fixed bonded lingual retainers). On the other
formed retainers) for six months, and then at night hand, it is very important to explain fully the
only for the next six months (21). importance of retainers and of proper handling
Statistical analysis: The data were collected and and regular checkups to patients (4). Patients need
subjected to computerized statistical analysis to be recalled after different time intervals in
using statistical Package for Social Science order to instruct, checkup, adjust, and remove any
computer software (SPSS, version 17), in which discomfort, therefore, in the current study,
the description for the non-parametric categorical different time intervals ( At time of retainer
variables represented by observed number and insertion, three months, six months, and one year
percentage of occurrence, while the inferential post-retainer insertion) were selected to evaluate
statistics included the use of Chi-square for the clinical performance of these retainers (19,20).
comparison of the categorical data among the four Tables one to four described the variables'
types of retainers. Probability levels of less than characteristics of clinical performance. Regarding
5%, 1%, and 0.1% were regarded as statistically the versatility (comfort and adaptability), the
significant, highly significant, and very highly Clear Advantage Series II durable invisible
significant, respectively. retainer (CII) showed that there was an inferior
Method error: It was calculated to determine the categorical description property expressed by a
reproducibility and reliability of the categorical low observed numbers and percentages of
descriptions of clinical performance, the occurrence at the time of retainers insertion, the
categorical descriptions of five patients were superior and acceptable categorical descriptions
evaluated two times, first by the researcher, and increase after three months, then became the same
second time by another observer. Kappa test description after six months and one year post-
(GraphPad Software, Inc.; USA) was used to retainer insertion, while the Clear Advantage
evaluate the inter-observer agreement, it was Series I standard thermo-vacuum formed
found equal to 0.8 which indicates a very good invisible retainer (CI) showed an increase in the
strength of agreement. (4,22). superior and acceptable categorical descriptions
from the time of insertion to three months post-
insertion, this may be due to adaptation of
RESULTS AND DISCUSSION stomatognathic system to the new appliance
There are insufficient data on which to base our inserted inside the patient's mouth, the inferior
clinical practices on retention present, several description increases from six months to one year
retainer designs have examined over time, with post-insertion, this may be due to cracks produced
various retention protocols to minimize relapse at the margins of the retainer that can reduce the
(19,23-25)
. Because of the lack of scientific evidence adaptation and comfort of the patient to this type
on retention protocols, it appears that previous of retainer. The Hawley retainer (HR) showed an
recommendations are based largely on personal increase in the superior and acceptable categorical
preference and non-scientific criteria (4,25). The descriptions from time of insertion to the three
clinical performance of different retainers' types is months post-insertion due to the adaptation
a vital area of orthodontic research, and it should process, while the inferior description increases
be given priority on our concern. As far as being from six months to one year post-insertion, this
aware, no research has been published that may be due that such type of retainer contains
addresses the evaluation of the clinical thick and bulk acrylic base plate and orthodontic
performance of different retainers' types. wires that are liable to deformation and need
Many studies conducted onto survey the periodic adjustment, so the versatility decreased
orthodontic trends over the past 25 years in
with time, so that it will negatively affect the due to the bad taste of the etchant and primer,
adaptation and comfort. The fixed bonded lingual which can negatively affect the taste, then with
retainer (FR) showed an increase in the superior time there will be an increase in the inferior
categorical description with time, this may also be property of bad taste and odor, due to unhygienic
due to adaptation of the tongue to the fixed plaque accumulation property of this type of
bonded lingual retainer. retainer (9,10).
Regarding the esthetic point of view the CII, Regarding the caries risk, all types of
CI, and FR showed high observed numbers and removable retainers showed high observed
percentages of occurrence for superior and numbers and percentages of occurrence of
acceptable descriptions, this is due to the superior categorical description property and
translucent property of clear invisible (CII and CI) remained high with time, except the FR showed
retainers, even though the CII retainer is slight high inferior property with time because of
cloudy than the CI retainer, but when the CII difficulty in maintaining good oral hygiene with
retainer is subjected to heat during thermal such type of retainer, while all removable
vacuum forming process, such cloudiness is retainers can be removed outside the patient's
decreased and became unnoticeable when the CII mouth, so it is better to perform a good oral
is inserted inside the patient's mouth, so both hygiene maintenance with such type of retainers
(9,10)
types of clear invisible (CII and CI) retainers .
exhibited superior and acceptable properties, the Regarding soft tissue irritability, CII and CI
fixed bonded lingual retainer (FR) was positioned retainers showed high observed numbers and
lingually, therefore it exhibits better esthetic, percentages of occurrence of the superior
while the HR showed an increase of the superior categorical description property and remained the
and acceptable categorical descriptions with time, same with time because both retainers' thickness
this may be due to better psychological were one millimeter and contained no wires, so
adaptation to the shape of this retainer. less soft tissue irritability, while HR showed high
Regarding the speech, all types of retainers inferior property and remained the same observed
showed increase in the superior and acceptable numbers and percentages after three months, six
categorical descriptions with time due to the months , and one year post-insertion, because this
adaptation of the patient's tongue and lips to the type of retainers contained wires and relatively
retainers with time factor, so phonetic thick bulky acrylic base plate that can affect on
improvement will occur. the surrounding soft tissue. However, it is well
Regarding the retention, the CII and CI known that the major advantage of HR is the
retainers showed superior categorical description, ability of the patient to perform optimal oral
and not affected by time, because these retainers' hygiene care, the major disadvantage of such
types depend on negative pressure, accurate retainer is the acrylic base plate, which is
fitness, and interfacial forces to achieve their basically thick and bulky, such bulk affects
retention (3,4,23), while the HR showed increase in speech negatively, potentially toxic irritable and
the inferior categorical description with time unhygienic upon prolong wearing (8), some
because such type of retainers had wires that need authors said that HR allows vertical settling of the
periodic adjustment, the FR showed also increase teeth (29-31). But settling of teeth should be carried
in the inferior property with time, this may be due out during the last phase of active treatment rather
to the increase of the bonding failure of FR with than in the retention period (30-32), the FR showed
time, which can subsequently affect the overall high observed number and percentage of the
retention of this type of retainer. inferior categorical property and both increase
Regarding the bad taste, the CII and CI with time, this may be due to the ability of this
retainers showed superior categorical description type of retainer to cause irritation to the
and not affected by the factor of time, while HR surrounding soft tissue due to plaque retentive
showed inferior description at time of insertion, ability, on the other hand, the major advantage of
this may be due to the residual monomer of the fixed retainer was the close relation between
methyl methacrylate, the inferior property the bonded teeth, resulting in their consolidation
decreases after three months and six months post- to act clinically as a stable dental unit, such
insertion, then the inferior property will increase consolidation maintains the position of the
after one year post-insertion, this may be due to dentition even in the presence of unfavorable or
microbial plaque accumulation at the acrylic base unbalanced soft tissue forces (9,33).
plate that can affect the taste and odor, this Regarding the construction time, CII and CI
explanation agreed with other research (8) , the FR invisible retainers showed high superior
showed high inferior property at time of insertion, categorical property, because such retainers need

about one hour from impressions till their A comparison of the total variables of the
insertion inside the patient's mouth, while HR clinical performance at total time intervals using
showed high inferior categorical property because chi-square showed that there was a significant
it needs one to seven days till retainer insertion difference (P<0.05) in the acceptable categorical
because it needs a laboratory work, so it can be description between CII and CI, as demonstrated
concluded that the thermoplastic invisible in table 6, this may be due to the significant
retainers (CII sand CI) showed a reduction in the difference of the acceptable categorical
laboratory fabrication, and the fabrication description between CII and CI retainers after 3
technique is simple and no technical proficiency months post-retainer insertion as shown in table 5,
in wire bending or knowledge of the properties of which it plays an important role in the final
dental laboratory acrylic is required, this is in difference between the two types of retainers as
accordance with other studies (16,18). shown in table 6, while a clinical performance
Regarding chair-side time, the CII retainer comparison between CII, HR, and FR showed
showed the highest superior categorical property, very high significant difference (P<0.001)
followed by CI, HR, and FR respectively, the between all categorical descriptions of these
superior property remains high with time, because variables for total time intervals, this may be due
CII retainer showed the most durable retainer, and to the very high significant difference of the
it does not need any repairing, subsequently less acceptable categorical description property
chair-side time, while the other retainers' types between CII, HR, and FR retainers after 3 months,
were more liable to repair, therefore, more chair- 6 months, and 1 year post-insertion as shown in
side time, the FR showed an increase in the table 5, so it can be concluded that the new CII
inferior property with time, because it exhibited retainer seems to have several advantages when
more debonding failures and subsequently more compared to the three standard orthodontic
chair-side time. It might be better to assess and retainers (CI, HR, and FR). Taking into
compare the number of failures and rebonding consideration, the main positive and negative
appointments, it might be that the increased aspects of the four types of retainers used in the
mobility of the teeth because of periodontal current study, it was thought that a combination of
problem in the post-treatment period favors removable, comfortable, aesthetic, better speech,
detachments, failures can be inherent, as a result superior retention, relatively not producing bad
of poor chair-side technique, or acquired, from taste and odor, hygienic, least soft tissue
wear or direct trauma to the retainer (34,35). irritability, superior construction and chair-side
Regarding failure of retention material, the CII time, and durable, will be more favorable
retainer showed superior categorical property appliance to both the patient and the orthodontist.
because this type of retainer is most durable However, the major disadvantage of the new CII
retainer than other retainers' types, and it does not retainer was that it does not bond to acrylic
be affected by the time factor, while the FR, CI, because polypropylene material of this type of
and HR showed inferior categorical property retainer is considered as a non-stick plastic,
changing from high to low respectively, this may basically it has inert or inactive molecular
be due to the multiple debonding failures of FR, structure, therefore described as a low energy
cracks and their propagation and subsequent state (29). There was a very high significant
fracture of the margins of CI, and fracture of the difference (P<0.001) in the superior and inferior
orthodontic wires and/or fracture of acrylic base categorical properties and non-significant
plate resulting in failure of the retainer, difference (P>0.05) in the acceptable categorical
respectively, as shown in tables one to four, so it description property between CI, HR, and FR for
can be concluded that the CII retainer overcomes total time of the total variables of clinical
the cracks and fracture problem often encountered performance, as shown in table 6, this may be due
with the use of CI and HR retainers and to the non-significant difference in the acceptable
debonding failures associated with FR. There is categorical description between CI, FR, and HR
little doubt that corrosive wear is an important after 6 months, and one year post-insertion,
factor in the durability of thermoplastic retainers, respectively, for total variables of clinical
chemicals and certain bicarbonated drinks can performance as described in table 5. So it can be
plasticize certain polymers (polypropylene of CII, concluded that the overall clinical performance
and copolyesters of CI retainers), temperature comparison between CI retainer and HR is as the
change of water inside patient's mouth can cause same as that between CI and FR, as demonstrated
filler leaching, and certain micro-organisms in table 6. There was a non-significant difference
produce esterase enzymes that can degrade (P>0.05) between HR and FR for all categorical
polymers(36,37) . descriptions at total time intervals, so it can be

concluded that HR and FR also exhibited the 19. Housten WJ, Issacson KG. Orthodontic treatment with
same overall clinical performance. In addition, it removable appliances. 2nd Edition, Bristol, Johan
Wright and Sons Limited. 1980; 152-62.
was found that patients were compliant with all
20. Schott T, Goz G. Applicative characteristics of new
types of retainers, and the compliance decreased microelectronic sensors Smart Retainer® and
at a much faster rate with both types of themo- Theramon® for measuring wear time. J. Orofac.
vacuum formed retainers (CII and CI ) than with Orthop. 2010; 71(5): 339-347. IVSL.
HR and FR. As a conclusion, patient's compliance 21. Destang DL, Kerr WJ. Maxillary retention: is longer
is greater with HR and FR retainers than with CII better? Eur. J. Orthod. 2003; 25; 65-69.
22. Nollet P, Katsaros C, Hof M, Bongaarts C, Semb G,
and CI retainers, this agreed with other researches
(25,38) Shaw W, Anne J. Photographs of Study Casts: An
. Alternative Medium for Rating Dental Arch
Relationships in Unilateral Cleft Lip and Palate. Cleft
Palate–Craniofac. J. 2005; 41(6):646-650.
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Figure 1: Retainers' materials, A: Clear

Advantage Series II durable retainer material,
B: Clear Advantage Series I retainer material,
C and D: Polymethyl-methacrylate "powder
and liquid" and 0.7mm hard stain-less steel
wire for fabrication of Hawley retainer, E and
F: Fixed lingual bonded retainers "cuspid to
cuspid" with assorted sizes bonded with light
activated orthodontic bonding system.
Figures 2 A - E: The Clear Advantage Series II

thermo-vacuum formed durable invisible retainer.
Figure 3: Clear Advantage Series I thermo- Figure 4: Hawley retainer inside a patient's mouth.
vacuum formed invisible retainer.
Figure 5: Fixed lingual bonded retainers "cuspid to cuspid"

Table 1: Descriptive statistics for the clinical performance evaluation of the four types of
retainers at the time of insertion using observed numbers and percentage of occurrence.
Clear Advantage Series II Clear Advantage Series I Fixed bonded lingual
Hawley retainer
Durable invisible retainer standard invisible retainer retainer
N=5
N=5 N=5 N=5
+ ± - + ± - + ± - + ± -
1 3 1 1 3 1 0 1 4 0 1 4
Versatility
(20%) (60%) (20%) (20%) (60%) (20%) (0%) (20%) (80%) (0%) (20%) (80%)
5 0 0 5 0 0 0 1 4 5 0 0
Aesthetic
(100%) (0%) (0%) (100%) (0%) (0%) (0%) (20%) (80%) (0%) (0%) (100%)
1 3 1 1 3 1 0 0 5 0 1 4
Speech
(20%) (60%) (20%) (20%) (60%) (20%) (0%) (0%) (100%) (0%) (20%) (80%)
4 1 0 4 1 0 4 1 0 5 0 0
Retention
(80%) (20%) (0%) (80%) (20%) (0%) (80%) (20%) (0%) (100%) (0%) (0%)
Bad taste and 5 0 0 5 0 0 1 2 2 1 1 3
odor (100%) (0%) (0%) (100%) (0%) (0%) (20%) (40%) (40%) (20%) (20%) (60%)
Caries risk
------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- -------
(Hygienic)
Soft tissue 5 0 0 5 0 0 1 1 3 1 2 2
irritability (100%) (0%) (0%) (100%) (0%) (0%) (20%) (20%) (60%) (20%) (40%) (40%)
Construction 5 0 0 5 0 0 0 1 4 1 3 1
Time (100%) (0%) (0%) (100%) (0%) (0%) (0%) (20%) (80%) (20%) (60%) (20%)
Chair- side 5 0 0 5 0 0 5 0 0 0 1 4
time (100%) (0%) (0%) (100%) (0%) (0%) (100%) (0%) (0%) (0%) (20%) (80%)
Failure of
retention ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- -------
material
31 7 2 31 7 2 11 7 22 13 9 18
Total variables
(77.5%) (7.55%) (5%) (77.5%) (7.55%) (5%) (27.5%) (7.5%) (55%) (32.5%) (22.5%) (45%)
+ : Superior . ± : Acceptable. - : Inferior. N: Number of subjects.
retainers after three months post- insertion using observed numbers and percentage of
occurrence.
Clear Advantage Series II Clear Advantage Series I Fixed bonded lingual
Hawley retainer
Durable invisible retainer standard invisible retainer retainer
N=5
N=5 N=5 N=5
+ ± - + ± - + ± - + ± -
4 1 0 4 1 0 1 3 1 1 1 3
Versatility
(80%) (20%) (0%) (80%) (20%) (0%) (20%) (60%) (20%) (20%) (20%) (60%)
5 0 0 5 0 0 1 1 3 5 0 0
Aesthetic
(100%) (0%) (0%) (100%) (0%) (0%) (20%) (20%) (60%) (100%) (0%) (0%)
3 1 1 3 1 1 2 2 1 0 2 3
Speech
(60%) (20%) (20%) (60%) (20%) (20%) (40%) (40%) (20%) (0%) (40%) (60%)
5 0 0 5 0 0 3 2 0 3 1 1
Retention
(100%) (0%) (0%) (100%) (0%) (0%) (60%) (40%) (0%) (60%) (20%) (20%)
Bad taste and 5 0 0 5 0 0 1 3 1 1 2 2
odor (100%) (0%) (0%) (100%) (0%) (0%) (20%) (60%) (20%) (20%) (40%) (40%)
Caries risk 5 0 0 5 0 0 5 0 0 0 2 3
(Hygienic) (100%) (0%) (0%) (100%) (0%) (0%) (100%) (0%) (0%) (0%) (40%) (60%)
Soft tissue 5 0 0 5 0 0 1 2 2 1 3 2
irritability (100%) (0%) (0%) (100%) (0%) (0%) (20%) (40%) (40%) (20%) (60%) (40%)
Construction
------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- -------
Time
Chair- side 5 0 0 1 4 0 1 4 0 1 1 3
time (100%) (0%) (0%) (20%) (80%) (0%) (20%) (80%) (0%) (20%) (20%) (60%)
Failure of
5 0 0 1 3 1 2 2 1 2 2 1
retention
(100%) (0%) (0%) (20%) (60%) (20%) (40%) (40%) (20%) (40%) (40%) (20%)
material
42 2 1 34 9 2 17 19 9 14 13 18
Total variables
(93.3%) (4.4%) (2.22%) (75.5%) (20%) (4.44%) (37.7%) (42.2%) (20%) (31.1%) (28.8%) (40%)
+ : Superior . ± : Acceptable. - : Inferior. N: Number of subjects

retainers after six months post- insertion. using observed numbers and percentage of occurrence
Clear Advantage Series II Clear Advantage Series I
Hawley retainer Fixed bonded lingual retainer
Durable invisible retainer standard invisible retainer
N=5 N=5
N=5 N=5
+ ± - + ± - + ± - + ± -
5 0 0 2 2 1 1 3 1 1 2 2
Versatility
(100%) (0%) (0%) (40%) (40%) (20%) (20%) (60%) (20%) (20%) (40%) (40%)
5 0 0 5 0 0 2 2 1 5 0 0
Aesthetic
(100%) (0%) (0%) (100%) (0%) (0%) (40%) (40%) (20%) (100%) (0%) (0%)
5 0 0 5 0 0 4 1 0 0 3 2
Speech
(100%) (0%) (0%) (100%) (0%) (0%) (80%) (20%) (0%) (0%) (60%) (40%)
5 0 0 5 0 0 3 2 0 3 1 1
Retention
(100%) (0%) (0%) (100%) (0%) (0%) (60%) (40%) (0%) (60%) (20%) (20%)
Bad taste and 4 1 0 4 1 0 1 3 1 1 2 2
odor (80%) (20%) (0%) (80%) (20%) (0%) (20%) (60%) (20%) (20%) (40%) (40%)
Caries risk 5 0 0 5 0 0 5 0 0 0 2 3
(Hygienic) (100%) (0%) (0%) (100%) (0%) (0%) (100%) (0%) (0%) (0%) (40%) (60%)
Soft tissue 5 0 0 5 0 0 1 2 2 1 1 2
irritability (100%) (0%) (0%) (100%) (0%) (0%) (20%) (40%) (40%) (20%) (20%) (40%)
Construction
------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- -------
Time
Chair- side 5 0 0 3 1 1 1 4 0 0 2 3
time (100%) (0%) (0%) (60%) (20%) (20%) (20%) (80%) (0%) (0%) (40%) (60%)
Failure of
5 0 0 1 2 2 1 3 1 1 1 3
retention
(100%) (0%) (0%) (20%) (40%) (40%) (20%) (60%) (20%) (20%) (20%) (60%)
material
44 1 0 35 6 4 19 19 6 12 15 18
Total variables
(97.7%) (2.2%) (0%) (77.7%) (13.3%) (8.8%) (42.2%) (42.2%) (13.3%) (26.6%) (33.3%) (40%)
retainers after one year post-insertion using observed numbers and percentage of occurrence.
Clear Advantage Series II Clear Advantage Series I
Hawley retainer Fixed bonded lingual retainer
Durable invisible retainer standard invisible retainer
N=5 N=5
N=5 N=5
+ ± - + ± - + ± - + ± -
5 0 0 2 1 2 1 3 2 2 2 1
Versatility
(100%) (0%) (0%) (40%) (20%) (40%) (20%) (60%) (40%) (40%) (40%) (20%)
5 0 0 4 1 0 3 1 1 5 0 0
Aesthetic
(100%) (0%) (0%) (80%) (20%) (0%) (60%) (20%) (20%) (100%) (0%) (0%)
5 0 0 5 0 0 4 1 0 0 3 2
Speech
(100%) (0%) (0%) (100%) (0%) (0%) (80%) (20%) (0%) (0%) (60%) (40%)
5 0 0 5 0 0 1 2 2 3 1 1
Retention
(100%) (0%) (0%) (100%) (0%) (0%) (20%) (40%) (40%) (60%) (20%) (20%)
Bad taste and 3 1 1 3 1 1 0 3 2 0 2 3
odor (60%) (20%) (20%) (60%) (20%) (20%) (0%) (60%) (40%) (0%) (40%) (60%)
Caries risk 5 0 0 5 0 0 1 4 0 1 1 3
(Hygienic) (100%) (0%) (0%) (100%) (0%) (0%) (20%) (80%) (0%) (20%) (20%) (60%)
Soft tissue 5 0 0 5 0 0 1 2 2 0 2 3
irritability (100%) (0%) (0%) (100%) (0%) (0%) (20%) (40%) (40%) (0%) (40%) (60%)
Construction
------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- -------
Time
Chair- side 5 0 0 1 2 2 1 3 1 0 1 4
time (100%) (0%) (0%) (20%) (40%) (40%) (20%) (60%) (20%) (0%) (20%) (80%)
Failure of
5 0 0 1 1 3 1 2 2 0 1 4
retention
(100%) (0%) (0%) (20%) (20%) (60%) (20%) (40%) (40%) (0%) (20%) (80%)
material
43 1 1 31 6 8 13 20 12 11 13 21
Total variables
(95.5%) (2.2%) (2.2%) (68.8%) (13.3%) (17.7%) (28.8%) (44.4%) (26.6%) (24.4%) (28.8%) (46.6%)

Table 5: Comparisons of the total variables of the clinical performance among the four types of
retainers at different times using chi square
CII and CI CII and HR CII and FR CI and HR CI and FR HR and FR
x2 Sig. x2 Sig. x2 Sig. x2 Sig. x2 Sig. x2 Sig.
+ 0.000 NS 9.521 HS 13.564 VHS 9.521 HS 13.564 VHS 0.472 NS
At time of Total
± 0.000 NS 0.000 NS 0.250 NS 0.000 NS 0.250 NS 0.250 NS
insertion variables _
0.000 NS 16.663 VHS 17.64 VHS 16.663 VHS 17.640 VHS 0.022 NS
After 3months + 0.842 NS 10.592 HS 14.000 VHS 5.666 S 8.332 HS 0.290 NS
Total
post- insertion. ± 4.454 S 13.760 VHS 18.066 VHS 3.570 NS 0.726 NS 1.124 NS
variables _
0.332 NS 6.400 S 15.210 VHS 4.454 NS 12.800 VHS 3.000 NS
After 6 months + 1.024 NS 9.920 HS 18.284 VHS 4.840 S 11.254 VHS 1.580 NS
Total
post- insertion ± 3.070 NS 16.200 VHS 12.250 VHS 3.380 NS 3.856 NS 0.470 NS
variables _
4.000 S 7.000 HS 18.000 VHS 0.818 NS 8.908 S 4.840 S
+ 1.944 NS 16.070 VHS 18.962 VHS 7.362 HS 9.522 HS 0.166 NS
After 1 year Total
± 3.570 NS 17.190 VHS 10.284 VHS 7.338 NS 2.578 NS 1.484 NS
ost-insertion variables _
5.444 S 9.306 HS 18.180 VHS 0.800 NS 5.826 S 2.454 NS
CII: Clear Advantage Series II Durable invisible retainer. HR: Hawley retainer.
CI: Clear Advantage Series I standard invisible retainer. FR: Fixed bonded lingual retainer.
NS: Non-significant (P>0.05) . S: Significant ( P< 0.05). HS: Highly significant (P<0.01).
VHS: Very highly significant (P < 0.001)
X2: Chi square. Degree of freedom=1.
Table 6: Comparisons of the total time and total variables of the clinical performance among the
four types of retainers using chi square
CII and CI CII and HR CII and FR CI and HR CI and FR HR and FR
x2 Sig. x2 Sig. x2 Sig. x2 Sig. x2 Sig. x2 Sig.
+ 2.890 NS 45.440 VHS 64.500 VHS 26.380 VHS 42.020 VHS 2.141 NS
Total Total
± 7.810 S 38.360 VHS 24.920 VHS 4.720 NS 6.200 NS 1.940 NS
time variables _
7.200 NS 39.180 VHS 68.760 VHS 17.500 VHS 42.660 VHS 6.920 NS
CII: Clear Advantage Series II Durable invisible retainer. HR: Hawley retainer.
CI: Clear Advantage Series I standard invisible retainer. FR: Fixed bonded lingual retainer.
NS: Non-significant (P>0.05) . S: Significant ( P< 0.05). HS: Highly significant (P<0.01).
VHS: Very highly significant (P < 0.001)
X2: Chi square. Degree of freedom=3.

J Bagh College Dentistry Vol. 24(2), 2012 Stimulation of rabbit
Stimulation of rabbit condyle growth by using pulsed

therapeutic ultrasound (A radiographical and histological
experimental study)
Mustafa A.Qaisi, B.D.S. (1)
Nidhal H. Ghaib, B.D.S., M.Sc. (2)
ABSTRACT
Backgrounds: Many difficulties faced the orthodontic clinician during treatment of class II malocclusion cases in the
preadolescence period in which treatment is done by growth modification of condyle , these difficulties are due to
the poor cooperation of the patients with the myofunctional appliances. The present research was carried out to
evaluate the effect of Low Intensity Pulsed Ultrasound application on mandibular condyle of rabbit radiographically
and histologically to evaluate the use of low intensity pulsed ultrasound in condyle growth modification in the
treatment of skeletal class II malocclusions in the growth period.
Materials and Methods: The sample was 15 New Zealand male rabbits in which Therapeutic Ultrasound was applied
to the left condyle (treated group) for 28 days while the right condyle was without ultrasound application (controlled
group), After animal sacrifying , the rabbit mandibles were dissected into two hemi mandible, left (treated) and
right (control), radiographic image for each hemi mandible was done and three linear measurements were made,
(Ramus height, condylar height and mandibular height). Then these hemi mandibles examined histologically
including calculating chondrocyte number, osteocyte number, cartilage area calculation and subchondral bone
area measurements.
Results: the results showed: The increasing of all linear measurements as a result of enhancement of chondrocytes,
osteocytes, increase of cartilage area and bone area in the treated group. There is significant correlation between
all linear measurements and chondrocyte and cartilage area.
Conclusion: low intensity pulsed ultrasound can accelerate condyle cartilage growth.
Key Words: therapeutic ultrasound, Low intensity pulsed ultrasound, condyle, growth modifications. (J Bagh Coll
Dentistry 2012;24(2):137-143).
INTRODUCTION
Class II malocclusions of skeletal origin are Ultrasound is a form of mechanical energy that is
routinely seen in the orthodontic office. Studies transmitted through and into biological tissues as
of the etiologic factors of Class II malocclusions an acoustic pressure wave at frequencies above
recognize that most Class II malocclusions are a the limit of human hearing, is used widely in
result of mandibular deficiency and not of medicine as a therapeutic, operative, and
maxillary excess (1). Most Class II patients diagnostic tool. Therapeutic US, and some
present with retrognathic mandibles and operative US, use intensities as high as one to
orthognathic maxillae. Patients with mandibular three W/cm2 and can cause considerable heating
deficiency and Class II malocclusion have a in living tissues. To take full advantage of this
spectrum of esthetic, skeletal, and occlusal energy absorption, physical therapists often use
characterstics (2,3). However, treating such such levels of US acutely to decrease joint
malocclusions in growing patients by using bite- stiffness, reduce pain and muscle spasms, and
jumping appliances is believed to produce improve muscle mobility (7,8). Low–intensity
satisfactory improvement in facial esthetics and pulsed US (LIPUS) has been reported to be
minimize the need for surgical intervention later. effective in angiogenesis enhancement during
There is evidence that compensatory growth wound healing. Recently, low-level therapeutic-
occurs at the tempromandibular joint, and pulsed US was used to enhance bone healing
especially the mandibular condyle in response to after fracture and after mandibular distraction
altered occlusal function in growing animals (4,5). osteogenesis.(9-11).LIPUS is a type of ultrasound
Rabie et al. (6) studied osteogenesis in the that promotes tissue healing. For such use, US is
glenoid fossa in response to mandibular administered in pulses at lower intensity levels
advancement. They reported that mandibular than in physiotherapy (0.5 to 3.0 W/cm2), below
protrusion resulted in the osteoprogenitor cells 0.1 W/cm2 (12) The mechanisms involved in this
being oriented in the direction of the pull of the process which include mechanotransduction of
posterior fibers of the disk (viscoelastic pull) and micromechanical stimuli, will increase local
also resulted in a considerable increase in bone angiogenesis and improved blood supply and
formation in the glenoid fossa. aggrecan gene expression (13-15). LIPUS has also
(1) M.Sc. Student, Department of Orthodontics, Dental College, been used on growing cartilage. This stimulus
University of Baghdad. has been effective increasing cartilaginous
(2) Professor, Department of Orthodontics, Dental College,
University of Baghdad. growth potential in primary and secondary

cartilage (16,17, 18). El-Bialy et al (17,18) applied zirconate –titnate transducer and consisted of a
LIPUS (30 mW/cm2, 1.5 MHz) (Exogen Device) 200 –microsecond burst of 1 MHz sine that
on the temporomandibular joint (TMJ) region of delivered 50 mW/cm2 (model: HEALOSONIC,
growing rabbits and baboon monkeys for 20 New Delhi, India) (17,19,20) (Fig1), After four
minutes daily. Their results show a significant weeks, all waves animals were sacrificed
increase in mandibular cartilaginous growth humanly by intravenous injection of 1 mL/kg
under LIPUS stimulation, especially under sodium pentobarbitone, The mandibles were
chronic mandibular advancement. The surgically removed, divided at the symphyseal
mechanisms that may favor growth could include junction into 2 hemi mandibles by straight hand
the same mechanisms involved when bone piece (Fig 2).
healing is enhanced with LIPUS.
MATERIALS AND METHODS

The materials used in this study could be
classified into three major categories; the
pharmacological materials, materials used for
radio graphical examination and the materials
used for the preparation of histological sections.
The sample consisted of 15 male New
Zealand - white rabbits of 10-11 weeks of age
and the rabbits were kept in the animal
department of National Center for Drug Control
and Research/Baghdad-IRAQ in separate cages
in a 12-hour light/dark environment at a constant Figure 1: Application of LIPUS
temperature of 23°C and provided with food and
water ad libitum. The health status of each rabbit
was evaluated by a day body weight monitoring
for two week before start of the experiment as
well as during the time of the experiment.
According to the ultrasound application protocol,
the mandibles in each rabbit were divided into
two groups:
1-Control group (non treated group): which
was the right side of the mandible (right
condyle).
2-Ultrasound group (treated group): in A
which LIPUS of 50 mW/cm2 intensity ,1 MHz
frequency was applied for 20 minutes /day for
four weeks to the left side (left condyle) of the
mandible in each rabbit.
All rabbits were adapted to their cages
environment for two weeks before experiment.
On the day before experiment, each rabbit was
shaved in his left condyle region , This procedure
was repeated every four days to ensure that the
condyle area will be totally shaved along the
total period of experiment, the application of
LIPUS was done after sedation of rabbits by
using intramuscular injections of xylazine (2
B C
mg/kg) , ultrasound transducer was attached Figure 2: A-Surgical removal of mandible
securely to the surface of the shaved condyle B- Right hemi mandible
with turnica, ultrasound gel was used to couple C- Left hemi mandible
the ultrasound energy between transducer and
skin surface, This procedure was repeated for 20
minutes/ day for four weeks in which pulsed
ultrasound waves were applied by conventional
therapeutic ultrasound device of 3-cm lead

Figure 3: A- tracing of a hemi mandible B

showing linearmeasurements taken to
evaluate differential mandibular growth
changes(17) B- tracing of left hemi mandible
by using Auto Cad
All hemi mandibles were radiographed with the 50% formic acid and 20% sodium citrate. The
X-ray machine, transferred to the laptop by condylar head and necks were embedded in
making photographic picture to it using digital paraffin, then 5 µm thick sections were cut in the
camera (Sony Cyber shot) ,then each hemi sagittal plane with microtome, The tissue
mandible was traced using (auto cad 2008) sections were mounted on glass slides to be
program (with control of magnification by rod as stained with hemotoxylin and eosin, The finished
standardization).The x ray tracing identified three slides were examined using microscope and
anatomic points. Three anatomic parameters, two photomicrographs were taken at 40x power after
representing anteroposterior mandibular length placing an eye piece with a grid to calibrate the
and one representing mandibular ramus height, measurements, Then the photomicrographs were
were evaluated on the tracing of each hemi transferred to computer software (Auto Cad
mandible .The points and plane and 2008). A calibration step was performed within
measurements are shown in (Fig3) and are listed the software to get the actual measurements.
below (17): At the slide photomicrograph of the condylar
1. Measuring points head, two sections were chosen for histological
• Infradentale: most anterior point on alveolar examination (anterior and posterior sections for
process below the mandibular central incisor. each condyle) in way that ensure about all
• Condylar point: most superior point on the condyle surface is measured, A subchondral
mandibular condylar summit. rectangular area of 2 mm2 was selected for all
• Angular process: the most posterior contour slides and subsequent measurements and counts
on the mandibular ramus. were performed within anterior and posterior
2. Planes and measurements sections which are represented by (Fig 4,5):-
• Mandibular plane: a tangent to the inferior 1- Number of chondrocytes.
border of the mandible. 2- Number of osteocytes.
• Condylar height: the distance measured 3- Cartilage thickness area.
between the condylar point and the angular 4- Bone area.
process. 5- Bone marrow area.
• Ramus height: the perpendicular distance The first two were counted manually, while the
from condylar point to the mandibular plane. cartilage area, bone area and marrow area were
• Mandibular height: the distance from calculated by the (Auto Cad 2008) software after
tracing of it manually. From tracing, the cartilage
condylar point to infradentale.
area was obtained, while for bone area it was
obtained by subtraction of marrow area form the
After rabbits were sacrified, the surgically
whole 2mm2 subchondral area (18).
dissected hemi mandibles were embedded in
10% buffered formalin for two weeks for fixation
and then decalcified using a solution containing

Figure 4: histological examination of left condylar Figure 5: histological examination of Right

condylar cartilage Cartilage
RESULTS in the US-treated sides compared with the

The results included descriptive, comparative nontreated sides (Figure 2 A).
and correlation statistics for the anthropometrical 2-For the histological variables there was
and histological variables, the descriptive significant increase in the mean values of
involved the mean and standard deviation of the chondrocytes number, Osteocytes number,
three anthropometrical variables and of the four Cartilage thickness area and Bone area in the US-
histological variables measured in this study, treated condyle Compared with the untreated
while for the comparative statistics Student’s t- condyles.
tests for independent groups were performed, and For the correlation statistics between histological
a significance level of P , .05 was selected. and anthropometrical variables, there was
Statistical analysis was done, using SPSS significant correlation between mandibular height,
(version 15) software. As shown in (Table 1,2) condylar height and ramus height with chondrocyte
1-For the anthropometrical there was a numbers and cartilage area in the US treated hemi
significant increase in the mandibular ramus mandible while the anthropometric parameters did
height condylar height and mandibular height in not show significant correlation with histological
the US-treated hemi mandibles compared with measurements in the right control side, except there
the untreated hemi mandibles. Enlarged condyles was indirect significant correlation between ramus
and increased ramal height were clearly observed height and bone area (Table 3, 4).
Table 1: Descriptive & Comparative statistics for saggital jaw linear measurements
US treated (Left ) hemi Control (Right) hemi Linear difference
Variables mandibles (N=15) mandibles (N=15) (t-test)
Mean ±SD Mean ±SD t D.F P
Sagittal MH* 52.06 1.33 49.97 1.59 3.889 28 0.001**
jaw linear CH* 18.96 0.48 17.18 1.15 5.498 28 0.000***
parameters
RH* 31.89 0.83 29.54 1.755 4.696 28 0.000***
(mm)
MH= Mandibular Height, CH= Condylar Height, RH= Ramus Height

Table 2: Descriptive & Comparative statistics for Histological examination

US treated (Left ) Control (Right) condyle Histology difference
Histological
condyle(N=15) (N=15) (t-test)
variables
Mean ±SD Mean ±SD t D.F p
Chondrocyte No. 473.53 35.49 345.86 58.49 7.227 28 0.000***
Osteocyte No. 363 42.75 221.73 39.73 9.373 28 0.000***
Bone area (mm2) 1.66 0.036 1.61 0.04 3.193 28 0.003**
Cartilage thickness area
0.21 0.037 0.16 0.033 3.763 28 0.001**
(mm2)
Table 3: Correlation analysis between the sagittal jaw linear measurements and Histological
measurements of the left hemi mandible
Variabl Chondrocyt Osteocyt Bone Cartilag
e e e area e area
r 0.843*** 0.138 -0.131 0.736**
MH
P 0.000 0.625 0.641 0.002
r 0.565* 0.202 -0.124 0.570*
CH
P 0.031 0.470 0.659 0.026
r 0.692** 0.406 -0.239 0.661**
RH
P 0.004 0.133 0.391 0.007
Table 4: Correlation analysis between the sagittal jaw linear measurements and Histological
measurements of the right hemi mandible
Variable Chondrocyte Osteocyte Bone area Cartilage area

r 0.063 0.450 - 0.497 0.101
MH
p-value 0.823 0.092 0.059 0.720
r 0.061 0.374 - 0.368 - 0.009
CH
p-value 0.830 0.169 0.177 0.974
r 0.247 0.437 - 0.578* 0.175
RH
p-value 0.374 0.104 0.024 0.533
DISCUSSION
This study was performed primarily to find out animal studies were particularly interesting
if there is any stimulatory effect of low intensity because they pointed toward the biological
pulsed ultrasound (LIPUS) on condylar cartilage effects of LIPUS stimulation, in which using a
and on mandibular growth as a whole in growing conventional LIPUS device which was able to
rabbits. The rabbit model was chosen for this produce US emissions of appropriate
study because of the relatively large mandible characteristics, as evaluated from the biological
and skull. The age of rabbit was 10- 11 weeks response secondary to its use. This is reported by
because in this age the rabbit is in growth spurt Rodrigo et al., ( 2009)(24) study in which the
(21)
, the device which was used is the results suggested that the biological response
conventional Therapeutic ultrasound apparatus may vary and increase when LIPUS was applied
that is adapted for LIPUS emission. for 20 minutes instead of 10 minutes daily. The
To date, the studies that have been published in amount of ultrasound transmission to the control
the orthodontic literature regarding the use of side was negligible in which the intercondylar
LIPUS and its influence on condylar growth distance has been reported to be about four cm
have been performed using the standard LIPUS producing negligible exposure to the condyle on
device (Exogen, Caldwell, NJ)(17,18) , and this the other side (17)
device has been extensively proven in humans The linear measurements of condylar height,
(22)
and animals (16,23). ramal height, and mandibular height were chosen
Despite this, other LIPUS emission settings because previous studies on mandibular growth
have been reported by using conventional in rabbits showed significant changes in the
ultrasound devices (19) in which varying the ramal height and mandibular length in rabbits in
emission settings within the range of what is which the rabbit condyles growth selectively
defined as LIPUS. The results presented in the inhibited by intra-articular papain injection(25).
use of conventional Ultrasound devices in these The increase of all anthropometric measurements

occurred due to the fact that ultrasound waves ultrasound on the condyle of rabbit. In the
can increase chondrogenesis (26, 27). The greatest present study, the aim was not to study the
increase was in the condylar height measurement radiographic effect alone but to clarify the
and this could be due to the increase of cartilage quantitive histological effect on rabbit condyle if
thickness in vertical dimension more than in it present. the significant increase in the number
anterior and posterior dimension as most of of chondrocytes in the US treated side could be
chondrocyte located in the larger upper surface due to ultrasound wave effect by which it can
of condyle more than in the anterior and stimulate the chondrocyte proliferation and
posterior surfaces. chondrogenesis-associated gene expression(26,27),
The previous study of the effect of pulsed which lead to increase the mesenchymal cells
therapeutic ultrasound on rabbit condyle by (17) differentiations to chondroblasts then
revealed only the radiographical effect of chondrocytes. While the increase in osteocytes
number in the left condyle may be due to the due ultrasound wave ability to change
increase in the vascularization which happened permeability of chondrocytes leading to the
due to the minimum thermal effect of ultrasound increase of intracellular level of Calcium in the
that increase blood supply by blood vessels chondrocytes and increase in calcium
dilations and due to non thermal effect in which incorporation into differentiating cartilage and
Ultrasound waves are able to stimulate bone cell cultures (31) and this can enhance the
mandibular Osteoblast to proliferate and produce mineralization of bone. the significant increase
angiogenesis – related cytokines (28), All of these in cartilage area in US treated side may be
factors will lead to increase osteocyte happened due to the increase of extracellular
nourishment which could increase the osteocyte matrix of cartilage by the action of ultrasound
activity and maturation and formation of other waves in the enhancement of FGF which are
osteocyte .Also it could be as a result to the responsible for fibroblast growth (28) also due to
increase of chondrocyte cells which will pass in increase in chondrocytes number , and that will
the different stages to form osteocytes (29). The lead to increase collagen II, X type’s production .
significant increase in treated side bone area may The presence of significant correlation in left
be due to the effect of ultrasound which can condyle may be due to the increase in the
enhance FGF and VEGF (28), also ultrasound can chondrocyte number which will lead to the
enhance the process of endochondral ossification increase of extracellular matrix formation which
(16)
.Furthermore Ultrasound can affect results in the increase of cartilage area. The
Osteogenesis in which Osteoblasts can be increase in cartilage thickness will effect on the
stimulated to increase collagen production and condylar point position and this in the end will
increase the production of Prostaglandin E2 affect in a direct relation to all linear
(30)
.and all of these factors are responsible for measurements because all of these measurement
bone matrix formation which will lead to share the same condylar point.
increase of bone area. Also, It probably occur
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J Bagh College Dentistry Vol. 24(2), 2012 The relation between W
The relation between W angle and other methods used to

assess the sagittal jaw relationship
Sara M. Al-Mashhadany, B.D.S, M.Sc. (1)
ABSTRACT
Background: This study aimed to evaluate the mean value for the W angle in Iraqi adults with a Class I, II, and III
skeletal relations and to verify the existence of sexual dimorphism, also to study the correlation between this angle
with the other methods (ANB, Wits appraisal, BETA angle, YEN angle) used for evaluation of the antero-posterior (AP)
jaw relationship.
Materials and methods: One hundred and fifty-two cephalometric radiographs of patients between the age of 18
and 25 years were selected. They were again subdivided into Classes I, II, and III groups on the basis of Beta angle,
Wits appraisal, and ANB angle, traced using AUTO CAD 2007. The W angle was measured between the
perpendicular from point M on S–G line and the M–G line. The mean and the standard deviation for the W angle
were calculated. Independent sample t- test, the one-way analysis of variance, LSD and Pearson correlation were
obtained.
Results: The results showed that a patient with a W angle between 51 and 56 degrees can be considered to have a
Class I skeletal pattern. With an angle less than 51 degrees, patients are considered to have a skeletal Class II
relationship and with an angle greater than 56 degrees, patients have a skeletal Class III and there is significant
difference in the mean value of W angle among the three skeletal patterns with a no gender difference. The W
angle had a negative significant relation with ANB in all three classes and with WITS appraisal in class III group, while it
had a positive significant relation with BETA and YEN angles in all the three skeletal relations.
Key words: W angle, Antero-posterior jaw relationship. (J Bagh Coll Dentistry 2012;24(2):144-149).
INTRODUCTION To overcome these existing problems, a

In orthodontic diagnosis and treatment measurement was developed and named the W
planning, great importance has been attached to angle. It is a new measurement for assessing the
evaluating the sagittal apical base relationship. skeletal discrepancy between the maxilla and the
Both angular and linear measurements have been mandible in the sagittal plane (Figure 1). It uses
incorporated into various cephalometric analyses three skeletal landmarks—point S, point M, and
to help the clinician diagnose anteroposterior (AP) point G—to measure an angle that indicates the
discrepancies and establish the most appropriate severity and the type of skeletal dysplasia in the
treatment plan(1). Since Wylie’s (2) first attempt sagittal dimension (11).
to describe AP jaw relationship, various other The purposes of this study were to define the
cephalometric parameters have been proposed. Of mean value for the W angle in Iraqi adults with a
these parameters, the ANB angle (3) , the Wits Class I, II, and III skeletal relations and to verify
appraisal (4), and recently Beta angle (1) are the the existence of sexual dimorphism, also to study
commonly used parameters. Still, sagittal jaw the correlation between this angle with the other
relationships are difficult to evaluate because of methods used for evaluation of the antero-
rotations of the jaws during growth, vertical posterior (AP) jaw relationship.
relationships between the jaws and the reference
planes, and a lack of validity of the various MATERIALS AND METHODS
methods proposed for their evaluation (1, 4-6 ). To assign samples to the Classes I, II, and III
To determine true apical base relationship skeletal pattern groups, many files of individuals
independent of the cranial reference planes or between 18 and 25 years were screened in the
dental occlusion, Beta angle was developed(1). Orthodontic Department of Baghdad University.
The other problem is locating point condylion. After the initial selection, all x-rays were
The reproducibility of the location of condylion traced using AUTO CAD 2007; the ANB and
on mouth-closed lateral head films is limited (7- 9) . Beta angles and the Wits appraisal were measured
Most recently introduced sagittal dysplasia by each investigator separately. The mean values
indicator is YEN angle (10). But since it measures of those measurements were calculated.
an angle between line SM and MG, rotation of For a patient to be included in the Classes I,
jaw because of growth or orthodontic treatment II, or III skeletal pattern group, criteria for Beta
can mask true basal dysplasia, similar to ANB angle along with one of two (ANB angle and Wits
angle. appraisal) had to be met. A skeletal Class I
relationship was indicated by an ANB of 2–4
(1) Assistant Lecturer. Department of Orthodontics, College of degrees, a Wits coincidence of AO and BO in
Dentistry, University of Baghdad
females or BO 1 mm ahead of AO in males, and a

Beta angle of 27–35 degrees, Of the 70 patients Cephalometric measurements

initially selected class I, only 54 met the criteria to 1. ANB angle: The angle between lines N-A and
be included after retracing and remeasuring their N-B. It represents the difference between SNA
pretreatment caphalometric x-rays. Therefore, and SNB angles or it may be measured directly as
Group I consisted of 54 patients 28 male, 26 the angle ANB (3, 16).
female). 2. Beta angle: which is the angle between the
A skeletal Class II relationship was indicated perpendiculare line from point A to C–B line and
by an ANB of greater than 4 degrees, a Wits the A–B line (1).
appraisal with AO ahead of BO in females or AO 3. The YEN angle: which is the angle between
coinciding with or ahead of BO in males, and a the M–G line and the M–S line (10).
Beta angle less than 27 degrees, Of the 58 patients 4. The W angle: This is the angle between the
initially chosen as Class II, 40 (18 female, 22 perpendicular line from point M to S–G line and
male) met the criteria . the M–G line (11).
The skeletal Class III individuals were 5. AO-BO(mm): the distance between
characterized by an ANB less than 2 degrees, a perpendiculars drawn from point A and point B
Wits BO ahead of AO in females or BO ahead of on to the occlusal plane (4)
AO by more than 1 mm in males, and a Beta
angle greater than 35 degrees, Of the 65 patients Statistical analysis:
initially chosen as Class III, 58 (28 female, 30 Collected data were subjected to a computerized
male) met the criteria . statistical analysis using SPSS version 15 (2006)
computer program. To summarize the data,
Cephalometric Bony Landmarks and lines means, standard deviations, minimum and
1. Point S (Sella): The midpoint of the maximum of W angle in three groups were
hypophysial fossa (12). calculated, comparison between both genders is
2. Point N (Nasion): The most anterior point on done by using independent sample t-test. The one-
the nasofrontal suture in the median plane (12). way analysis of variance (ANOVA) was used
3. Point A (Subspinale): The deepest midline followed by LSD to determine whether there was
point on the premaxilla between the Anterior a statistically significant difference between the
Nasal Spine and Prosthion (13). mean values W angle of the three groups and
4. Point B (Supramentale): The deepest between each tow groups when there is significant
midline point on the mandible between difference, Pearson’s correlation coefficient also
Infradentale and Pogonion (13). used to study the correlation between W angle and
5. Point C (center of the condyle ):found by ANB, YEN angle, BETA angle and Wits
tracing the head of the condyle and approximately appraisal.
its center ( 1). In the statistical evaluation, the following level of
6. Point M: midpoint of the premaxilla (14). significance is used:
7. Point G: centre of the largest circle that is Non-significant NS P>0.05
tangent to the internal inferior, anterior, and Significant * 0.05 ≥ P>0.01
posterior surfaces of the mandibular symphysis (14, Highly significant ** 0.01 ≥ P>0.001
15)
. Very highly significant *** P≤0.0001
8. N- A line: Formed by a line joining Nasion
and point A (13). RESULTS
9. N- B line: Formed by a line joining Nasion The descriptive statistics of the five methods
and point B (13). used to assess the antero-posterior skeletal relation
10. Functional occlusal plane: drawn through the in male and female groups and their gender
cuspal overlap of maxillary first molar and difference are shown in (table 1).
bicuspid (4). Table 2 shows the descriptive statistics including
11. Line connecting S and M points. mean , standard deviation, standard error ,minimum
12. Line connecting M and G points and maximum for the total sample, also it shows the
13. Line connecting S and G points. comparison between the three skeletal relation using
14. Line from point M perpendicular to the S–G f-test followed by LSD test to show the statistical
line. between each two skeletal pattern (table 3).
15. Line connecting C and A points. Table 4 reveals the correlation between W angle
16. Line connecting C and B points and ANB, YEN angle, BETA angle and Wits
17. Line connecting A and B points. appraisal; Pearson’s correlation coefficient used
18. Line from point A perpendicular to the C–B to study the correlation in each skeletal relation.
line.
DISCUSSION • Any change in the angulation of the functional

Cephalometric radiograph is a valuable tool in occlusal plane caused by either
orthodontic diagnosis and treatment planning. normal development of the dentition, or by
Even before Angle introduced his classification of orthodontic intervention could profoundly
malocclusion to the profession in the early 1900s, influence the Wits appraisal(1).
the anterposterior relationship of mandible to A popular recent alternative Beta angle avoids use
maxilla was the most important diagnostic of functional plane and is not affected by jaw
criterion. This relationship can be determined rotations But it uses point A and point B, which
from clinical observation to some degree, but it can be remodelled by orthodontic treatment and
can be much more accurately evaluated from a growth(1). Furthermore, as shown by various
lateral radiograph (17).Assessing this sagittal studies, the reproducibility of the location of
relationship is a challenging issue in orthodontics. condylion on mouth-closed lateral head films is
The ANB angle has been recognized as a skeletal limited (8,9), Instead of condylion, centre of
sagittal discrepancy indicator and has become the condyle could be used, but approximation of
most commonly used measurement since that centre of condyle is difficult (1).
time. Steiner agreed with Reidel that SN plane In the present study the mean value of BETA
could be used as reference line because both angle in class I, II and III pattern as shown in
points are osseous structures that are easily visible (table 2) were nearly the same result of Baik and
in lateral cephalogram (16). Ververidou, with a highly significant differences
More recently, it has been claimed that among the three skeletal relation and a non
the ANB angle is affected by several significant gender differences, table 4 showed that
environmental factors and thus a diagnosis based BETA angle had a negative significant relation
on this angle may give false Results. with ANB in class III and with WITS in all
The following factors have been reported to affect classes but a positive relation with YEN angle in
the ANB angle: class III and with W angle in all skeletal classes.
• The patient’s age. Most recently introduced sagittal dysplasia
• The change of the spatial position of the nasion indicator by Neela et al. is YEN angle. But since
either in the vertical or anteroposterior direction it measures an angle between line SM and MG,
or both. rotation of jaw because of growth or orthodontic
• The upward or downward rotation of the SN treatment can mask true basal dysplasia(10), the
plane. mean value of YEN angle of the present study is
• The upward or downward rotation of the Jaws. nearly the same result of Neela et al., with a
• The change in the angle SN to the occlusal highly significant differences among the three
plane. skeletal relation (table 2,3) and a non significant
• The degree of facial prognathism(18-20). gender differences except in class II group (table
1).
Due to the above mentioned factors affecting the To overcome some of the limitations of the
accuracy of ANB angle measurement, a number previously discussed parameters, the W angle was
of different, new measurements have been developed. This measurement does not depend on
developed to determine the actual sagittal skeletal unstable landmarks or the functional occlusal
discrepancy. plane. It uses three stable points—point S, point
To eliminate the influence of the anatomic M, and point G (11). The mean value and standard
variations in nasion on the sagittal relationship of deviations of W angle of the three skeletal
the jaws, Jacobson 1975 presented the Wits relations had been shown in (Table 2) and this
appraisal to obtain a measurement that was less results is similar to Wasundhara.etal.
affected by variations in craniofacial Receiver operating characteristics curves showed
physiognomy. However there were difficulties that a W angle between 51 and 56 degrees can be
with this analysis as it was influenced by the considered to have a Class I skeletal pattern. With
following factors: an angle less than 51 degrees, patients are
• The occlusal plane was not easily reproducible, considered to have a skeletal Class II relationship
especially in mixed dentition and with an angle greater than 56 degrees, patients
cases where the teeth are not fully erupted. have a skeletal Class III.
• Patients with open bite, severe cant of occlusal One way ANOVA followed by LSD showed that
plane, multiple impactions, there was a highly statistically significant
missing teeth, skeletal asymmetry or steep curve difference between the mean value of W angle of
of spee. the three groups (table 2,3).between gender,
according to independent sample t-test, there was

no statistically significant difference between 3. Riedel RA. A cephalometric roentgenographic study

male and female groups (table 1). of the relation of the maxilla and associated parts to
the cranial base in normal and malocclusion of the
Table 4 showed that The W angle had a negative
teeth. Thesis, Northwestern University Dental School,
significant relation with ANB in all three classes 1948.
and with WITS appraisal in class III group, while 4. Jacobson A. The “Wits” appraisal of jaw disharmony.
it had a positive significant relation with BETA Am J Orthod 1975; 67: 125–138.
and YEN angles in all the three skeletal relations. 5. Moyers R E, Bookstein F L, Guire K E. The concept
The geometry of the W angle gives it the of pattern in craniofacial growth. Am J Orthod 1979;
76: 136–148.
advantage to remain relatively stable even when
6. Nanda R. Biomechanics and esthetic strategies in
the jaws are rotated or growing vertically. This is clinical orthodontics. Elsevier, St. Louis 2005: pp. 38–
a result of rotation of the S–G line along with jaw 73.
rotation, which carries the perpendicular from 7. Adenwalla S T, Kronman J H, Attarzadeh F. Porion
point M with it. Because the M–G line is also and condyle as cephalometric landmarks: an error
rotating in the same direction, the W angle study. Am J Orthod, 1988; 94: 411–415
8. Moore R N, DuBois L M, Boice P A, Igel K A. The
remains relatively stable. Therefore, measurement
accuracy of measuring condylion location. Am J
of W angle is useful sagittal parameter in skeletal Orthod 1989; 95: 344–347.
patterns with clockwise or counterclockwise 9. Ghafari J, Baumrind S, Efstratiadis SS.
rotation of the jaws as well as during transitional Misinterpreting growth and treatment outcome from
period when vertical facial growth is taking place serial cephalographs. Clin Orthod Res 1998; 1: 102–
(figure 2) (11). 106.
10. Neela P K, Mascarenhas R, Husain A. A new sagittal
From this study we can conclude that:
dysplasia indicator: the yen angle. World J Orthod
1. The W angle is a diagnostic tool to evaluate 2009;10: 147–151
the AP jaw relationship more consistently. 11. Wasundhara A. Bhad , Subash Nayak, Umal H. Doshi.
2. The mean value for the W angle in Iraqi adults A new approach of assessing sagittal dysplasia: the W
with a Class I, II, and III skeletal relations angle. Eur J Orthod 2011;
were 54.8, 49.6 and 59.83 respectively. . 12. Rakosi T. An atlas and manual of cephalometric
radiography. 2nd ed. London: Wolfe medical
3. There is statistically significant difference in
publications Ltd.; 1982. p. 7, 35, 40, 43, 45, 47-53, 61,
the mean value of W angle among the three 65, 85- 86, 135.
skeletal patterns. 13. Downs WB. Variations in facial relationship: their
4. There is no statistically significant difference significance in treatment and prognosis. Am J Orthod
between mean W angle values of males and 1948; 34(10): 812-40.
females. 14. Nanda R S, Merrill R M. Cephalometric assessment of
sagittal relationship between maxilla and mandible.
5. The W angle had a negative significant
Am J Orthod 1994; 105: 328–344
relation with ANB in all three classes and with 15. Braun S, Kittleson R, Kim K. The G-Axis: a growth
WITS appraisal in class III group, while it had vector for the mandible. Angle Orthod 2004; 74: 328–
a positive significant relation with BETA and 331. (IVSL)
YEN angles in all the three skeletal relations. 16. Steiner CC. Cephalometrics for you and me. Am J
Orthod 1953; 39(10): 729-55.
17. Freeman RS.Adjusting A-N-B anglees to reflect the
Clinical importance effect of maxillary position. Angle Orthod 1971; 41;
W angle adds a valuable tool for assessment of 332-5. (IVSL)
AP jaw relationship. Along with other parameters, 18. Chang HP. Assessment of anteroposterior
it should enable better diagnosis and treatment jawrelationship. Am J Orthod 1987; 92: 117- 22.
19. Walker Gf, Kowalski C. the distribution of the
planning for patients.
ANBangle in “normal” individuals. Angle Orthod
1971; 41; 332-5.
20. Kammalamma. Evaluation and correlation of beta
REFERENCES angle and wits appraisal in various skeletal
1. Baik C Y, Ververidou MA new approach of assessing malocclusion groups among patient visiting
sagittal discrepancies: the Beta angle. Am J Orthod government dental college,Bangalore. A master
2004; 126: 100–105. thesis.Department of orthodontist and dentofacial
2. Wylie WL. The assessment of anteroposterior orthopedics.Rajiv Gandi University of health science,
dysplasia. Angle Orthod 1947; 17: 97–109. (IVSL) Bangalore, 2009.

Table 1: Gender difference of the different methods in each of the three skeletal pattern using
independent sample t-test.
Male Female Gender difference
variable
mean S.D mean S.D T-test sig
ANB 3.44 0.9 3.069 0.9 1.512 0.13
WITS 0.776 1.7 -0.29 1.6 2.416 0.019
Class I BETA 31.68 2.6 31.03 2.8 0.874 0.38
W-angle 55.2 1.5 54.45 1.7 1.72 0.091
YEN-angle 123.3 2.1 122.1 2.3 2.077 0.053
ANB 6.955 1.5 7.111 1.6 -.315 0.754
WITS 4.094 1.8 3.862 2.2 0.36 0.721
Class II BETA 23.36 4.3 23.72 3.8 -.276 0.784
W-angle 49.59 1.8 49.61 1.8 -.036 0.972
YEN-angle 116.4 2.1 114.9 2.2 2.151 0.038
ANB -0.1 1.6 0.214 1.4 -.799 0.428
WITS -3.14 3.1 -3.35 2.3 0.291 0.772
Class III BETA 37.27 4.2 37.32 4.2 -.049 0.961
W-angle 59.9 2.2 59.75 2.6 0.235 0.815
YEN-angle 129.3 3.2 128.7 3.3 0.726 0.471
Table 2: Descriptive and comparative statistics among the three skelatal relations for the total
sample.
variables class N Mean S.D S.E Min. Max. F-test Sig.
Class I 54 3.24 0.91 0.1 1 5
ANB Class II 40 7.02 1.54 0.2 5 10 326.4 0.000
classIII 58 0.05 1.49 0.2 -4 3
Class I 54 0.20 1.68 0.2 -3.1 3.8
Wits(mm) Class II 40 3.99 2.01 0.3 1.01 9.75 125.5 0.000
classIII 58 -3.24 2.75 0.4 -12.3 1.3
Class I 54 31.33 2.7 0.4 26 35
BETA Class II 40 23.53 4.04 0.6 13 28 198.7 0.000
classIII 58 37.74 3.68 0.48 34 49
Class I 54 54.8 1.63 0.2 51 57
W_angle Class II 40 49.6 1.77 0.3 44 51 314.5 0.000
classIII 58 59.83 2.41 0.3 56 66
Class I 54 122.6 2.28 0.3 117 125
Yen_angle Class II 40 115.7 2.26 0.4 112 118 292.9 0.000
classIII 58 129 3.24 0.4 123 136
Table 3: Comparison between each two different skeletal pattern using LSD .
Class I-class II Class II- class III Class I-class III
Variables
Mean difference p-value Mean difference p-value Mean difference p-value
ANB -3.78 0.000 6.97 0.000 3.18 0.000
WITS -3.78 0.000 7.22 0.000 3.44 0.000
BETA 7.80 0.000 -14.21 0.000 -6.40 0.000
W-angle 5.19 0.000 -10.22 0.000 -5.03 0.000
YEN-angle 6.94 0.000 -13.3 0.000 -6.35 0.000

Table 4: The correlation between the variables in class I,II and III skeletal relations.
Variables class Yen W- angle BETA Wit
Class I .020 -.339-* -.125- .485**
ANB Class II -.522-** -.391-* -.135- .395*
Class III -.580-** -.680-** -.644-** .622**
Class I .044 -.098- -.301-*
Wits Class II -.108- -.103- -.512-**
Class III -.217- -.441-** -.822-**
Class I .154 .362**
BETA Class II .070 .381*
Class III .302* .564**
Class I .733**
W-angle Class II .579**
Class III .788**
**. Correlation is significant at the 0.01 level.

*. Correlation is significant at the 0.05 level.
Figure 1: The construction and mode of Figure 2: W angle remains relatively stable
measuring the W angle. even when jaws are rotated.

J Bagh College Dentistry Vol. 24(2), 2012 A comparative study
A comparative study evaluating the microleakage of

different types of restorative materials used in restoration
of pulpotomized primary molars
Zainab A. Al-Dahan, B.D.S., M.Sc. (1)
Aseel I. Al- Attar, B.D.S., M.Sc. (2)
Huda E.A. Al-Rubaee, B.D.S., M.Sc. (2)
ABSTRACT
Background: Possibly the greatest deterrent to the development of an ideal restorative material is the leakage that
occurs along the restoration, tooth interface. There is yet no truly adhesive dental material that exactly duplicates
physical properties of the tooth structure. This in vitro study was carried out to compare the microleakage of two
types of restorative materials used in pediatric dentistry Colored light curing compomer(Twinky star) and nano
ceramic restorative material (Ceram.x)) with that of amalgam by measuring their ability to prevent dye penetration.
Materials and Methods: Standardized Proximo-occlusal cavity preparations were prepared in 30 extracted sound
primary first lower molars. Pulpotomy was performed, and pulpotomy paste filled the pulp chamber with hard setting
cement over it all have same occlusal depth. The teeth were then randomly divided into three groups: Group A:
filled with Amalgam. Group B: filled with compomer (Twinky star). Group C: filled with nano ceramic (Ceram.x).
After that the teeth were stored in distilled water for 30 days at 37 °C in an incubator and during the period of storage
the teeth were subjected to 300 thermal cycles (10 cycles each day), then sectioned to be examined under the
stereo microscope.
Results: Data was analyzed using ANOVA test with help of spss soft ware, even though nano ceramic (Ceram. X)
showed higher resistance to dye penetration, when compared to compomer (Twinky star and amalgam), there
were no significant differences between the three studied groups in their resistance to dye penetration.
Conclusion: Depending on the ability to prevent marginal leakage, nano ceramic (ceram.x) and compomer (Twinky
star) restorative materials can be used as an alternative to amalgam in restoring pulpotomized primary teeth.
Key words: Amalgam, Colored light curing compomer, Twinky star, Nano Ceram.x restorative material,
Microleakage. (J Bagh Coll Dentistry 2012;24(2):150-154).
INRODUCTION
Adherence of the restorative material to the cavity The microleakage is determined today by many in
walls is one of the most important characteristics vivo and in vitro techniques such as; staining,
for it to be proven as an ideal material because it which, is the most preferred one(3). Many changes
prevents microleakage(1). Microleakage is defined have occurred in development and availability of
as the chemically undetectable passage of restorative materials for children. The amalgam
bacteria, fluids, molecules or ions between the has been used for more than 150 years as a
cavity walls and restorative materials. This restorative material due to its satisfactory clinical
seepage can cause hypersensitivity of restored characteristics: Low sensitive technique (moisture
tooth, tooth discoloration, recurrent caries, pulpal contamination), satisfactory longevity on primary
injury and accelerated deterioration of the teeth and diminished microleakage related to
restorative material (2) . One of the most important corrosive products in tooth/restoration interface.
problems today of the restorative dentistry is the In addition, amalgam is inexpensive and easy to
failure of restorative material to obtain a complete handle (4).
bond with the enamel and dentin, the formation of Compomers contain glass ionomer cement
microfissures, the penetration of ions, molecules, combined with visible light polymerized resin
bacteria and fluids into these fissures and the component. Their excellent physical properties
occurrence of postoperative pain, discoloration at along with fluoride releasing ability, minimal
the cavity edges, secondary decays and pulpal steps in placement and composite like esthetics
inflammations. It has been reported that this make them the strongest and most esthetically
phenomenon, referred to as the microleakage, is desirable material. Most restorative materials
due to the inadequacy of marginal adaptation show varying degrees of marginal leakage
between the restoration material and cavity wall. because of dimensional changes and lack of
adaptability to cavity walls. Microleakage
investigation of compomers and their
comparison with other materials have compared
(1) Professor. Department of Pedodontics and Preventive only a limited number of products but in general
Dentistry. College of Dentistry. Baghdad University. have shown adequately sealed restoration
(2) Assistant lecturer. Department of Orthodontics, Pedodontics margins(5).
and Preventive Dentistry. College of Dentistry. Al-Mustansiria
University.

Since nanotechnology was introduced to dentistry, no. 6 round bur while the depth of occlusal
nano composites with filler sizes ranging from preparation was (6mm) (measured from pulpal
0.01 to 0.04 mm have been developed. Nan floor to cuspal tip).The buccolingual width of
composites have many advantages, such as proximal box was( 4mm) and the gingival seat
reduced polymerization shrinkage, increased was located (2mm )coronal to CEJ . The length of
mechanical properties, improved optical proximal buccal and lingual walls was (4mm)
characteristics and better gloss retention(6) . (measured from gingival seat to cuspal tip (11).
Ceram·X (Dentsply DeTrey, Konstanz, Germany), Pulpotomy procedure was done for all teeth and
was developed after introduction of the floor of pulp filled with pulpotomy paste that is a
nanotechnology in dentistry, it's a light cured, mixture of one drop of euginol with one drop of
radiopaque restorative material for restoration of tricresol formalin mixed with zinc oxide euginol
anterior and posterior teeth. It combines powder then hard setting cement base of zinc
Nanotechnology, with improved organically phosphate cement was applied over it, and the
modified Ceramic particles (7). occlusal depth of cavity calibrated by reamer with
Nano ceramic (Ceram·X) contains glass fillers stopper to be the same depth from cusp tips to the
(1.1–1.5 μm) but differs from conventional hybrid cement base for all the teeth about 1.5mm (12).
composites by two important features: The teeth were divided into three groups of ten
methacrylate-modified silicon dioxide containing teeth each:
nano-filler (10 nm) substitute the microfiller that • Group A: was restored with amalgam.
is typically used in hybrid composites • Group B: was restored with compomer
(agglomerates of silicon dioxide particles). (Twinky star).
According to the manufacturer’s data, filler • Group C: was restored with nano ceramic
concentration is 76% by weight and 57% by (Ceram.X).
volume (6,7). The teeth were then stored in incubator for 30
Microleakage performance may be useful for days in distilled water at 37°C each day the teeth
comparative assessment of materials and selection were subjected to 10 thermal cycles (300 cycles).
of restorative materials with adequate marginal This procedure was done to simulate temperature
seal is directly related to the success and longevity changes in the oral environment which might
of the restorations (2). result in changes in the microspace around the
This study designed to assess the microleakage of restoration (13). Each tooth was placed in block
different restorative materials: of cold cure acrylic resin to seal the root apex and
1. Amalgam. furcation area to the area 1mm below the cement
2. Compomer (Twinky star). enamel junction, then the crown with the block
3. Nano ceramic (Ceram.x). was sealed with two layers of nail varnish to
Used in restoration of pulpotomized primary within approximately 1mm of the restoration
molars margins to prevent dye penetration in areas other
than the exposed margins (14-17). All the teeth were
MATERIALS AND METHODS immersed in 2% methylene blue dye solution at
Thirty sound human primary lower first molar 37°C in an incubator for 24 hours (1, 3, 10). Then
teeth free of dental caries extracted for all the teeth were removed from the dye and
orthodontic purpose (serial extraction) were washed under running water.
collected. After extraction; the teeth were cleaned Each tooth was then sectioned into two halves and
with rubber cup and pumice and scaled by ultra- two samples were prepared from each half by
sonic scalar to remove any calculus on the sectioning through the center of each restoration,
surfaces of the teeth. The teeth stored in distilled this provide two occlusal and two gingival
water containing thymol crystal 1%, at room margins allowing for identification of
temperature (8). microleakage through dye penetration. The degree
The teeth were examined for cracks by the use of of microleakage was determined by the degree of
magnifying eye lens. Any tooth associated with dye penetration from the margins of the
cracks was excluded and only sound teeth were restoration towards the pulp chamber by viewing
used (9). under a binocular stereo microscope with 10-20 X
Standardized class-II mesio-occlusal cavity was magnification (1).
prepared. A tungsten carbide fissure bur No.330 Under a stereomicroscope the teeth were studied
in a turbine hand piece was used with proper to measure the depth of dye penetration at the two
water cooling to prepare the cavities (10). surfaces of the cavity and the score which was
The buccolingual width of occlusal preparation higher was given as score to the particular tooth.
was (2.5mm) just enough to allow the entrance of All the scoring was carried out by a single person

and as seen clinically in figures (2), (3), (4), (5) cementoenamel junction for standardizations for
and scoring criteria used for the study was as the three restoratives materials to be the same to
follows (9): support the validity of the study design(9,18).
0 = No dye penetration Thermal cycling is commonly employed in dye
1 = Dye penetration between the restoration and penetration test of dental materials. The regimen
the tooth into enamel only. of thermal cycling was included in this study
2 = Dye penetration between the restoration and because it was commonly used in other previous
the tooth in the enamel and dentin. studies (1, 10, 19). The upper temperature (55°C) may
3 = Dye penetration between the restoration and be encountered in vivo, but it was perceived that
the tooth into the pulp chamber. higher temperature is relatively hot and may cause
ANOVA test was used to find any statistical discomfort and this two border of temperature
significant differences among the three studied (4°C and 55°C) simulating changes in temperature
groups. in oral cavity (in vivo) and also samples are
thermocycled through 30 days as aging process to
RESULTS see effect of time on the restoration (5,20).
Table (1) shows the descriptive statistics for the Many studies had been done on microleakage of
result of methylene blue dye penetration score for class II of posterior permanent teeth restorations
the three materials used in present study, this table and the findings obtained had been assumed to
shows that the higher mean score of dye apply to primary teeth, but some evidences
penetration was for compomer (Twinky star) suggest significant chemical and morphological
(1.80±0.92) followed by amalgam (1.70±1.16) differences between primary and permenant
and the lower mean was found for nano ceramic dentition This may be of fundamental importance
(Ceram.x) (1.20±1.03). ANOVA test showed no because of morphological differences such as a
significant difference among the three groups (F= larger tubular diameter and less mineralization of
0.952 P= 0.398). intertubular dentin areas (21,22). Furthermore,
The percentage of each score is shown in table information regarding microleakage in
(2), this table shows that percentage of teeth with restorations of pulpotomised primary human
absence of dye penetration (score 0) was higher molars are limited, for these reasons this study
among nano ceramic (Ceram. x) (30%) than both was done to estimate microleakage of different
amalgam (20%) and compomer (Twinky star) restorative materials in pulpotomized primary
(10%). On the other hand, concerning maximum human molars.
score of dye penetration (score 3) the higher The result demonstrates that none of the three
percentage of teeth was found for amalgam (30%) filling material was free from dye penetration.
followed by compomer (Twinky star) (20%) and Even though, nano ceramic (Ceram.x) showed the
lower percentage was found for nano ceramic least dye penetration with a mean score of
(Ceram.x) (10%). (1.20±1.03), while compomer(Twinky star)
Figure (1) shows that the percentage of dye demonstrated the greatest dye penetration with
penetration score (score2) was higher for teeth mean score of(1.80± 0.92), but there were no
filled with compomer (Twinky star) (50%) than significant differences between the three studied
both amalgam and nano ceramic (Ceram.x) groups.
(30%). The result data indicated no significant
differences between amalgam group and
Compomer(Twinky star) group, this results in
DISCUSSION agreement with Kitty et al(23), and Mass et al(22)
Dye penetration is used as a measure to evaluate who compared compomer with amalgam
the performance of the restorative materials. This restorations in primary teeth, they led to the
in vitro study was carried out to evaluate and conclusion that compomer may be recommended
compare the micro leakage of two new materials as alternative to amalgam in primary molars. Also
in the market and compare them with amalgam (9). the results agree with Marks et al(24) who reported
The standardized design of a class II cavity a 94% success rate for compomer after 3 years,
preparation and pulpotomy procedure for the which is an annual failure rate of 2% and
sound primary molars used in this study are more comparable to success rates in permanent teeth.
commonly representing the main percentages of The amalgam used achieved 88% success during
restorations done for children because most of the same period. Previous studies have also failed
patient come with severe pain because of pulpal to find significant differences between amalgam
involvement and most of them come with and compomers in relation to restoration failures
proximal lesions so cavity preparation in proximal
boxes extended to the enamel 2mm above

despite low failure rates, marginal integrity seems 9. Praphakar A Ra, Madan Mb, Raju O. The marginal
to be different. seal of a flowable Composite, an injectable resin
modified Glass lonomer and a Compomer in primary
The findings of this study showed no significant
molars - An in vitro study , J of Ind soci of Pedo and
difference between amalgam group and nano Prev Dent 2003; 21(2):45-48.
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with the results of Marcio et al(1) who leakage of polyacid modified composite resin
demonstrate that bonding agents and resin-based restorations in primary molars. An invitro study.J Appl
materials can exhibit excellent marginal seal for Oral Sci 2005; 13(2):175-178.
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From this in vitro study results, compomer restoration(in vitro study).A Master Thesis.
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25. Mass E, Gordon M, Fuks AB. Assessment of
and acid concentration on resin shear bond strength to
compomer proximal restorations in primary molars: a
primary tooth enamel. Am J Dent 1995; 5:237-239.
retrospective study in children. J Dent Child 1999; 66:
93-97.

Table 1: Dye penetration score (Mean±SD) for the three studied groups
Groups Mean ±SD F d.f Sig
Amalgam 1.7 1.16
Twinky Star 1.8 0.92 0.952 2 0.398
Ceram.X 1.2 1.03
Table 2: Percentage for score of dye penetration of the three studied groups
Groups Amalgam Twinky Star Ceram.X
Scores No. % No. % No. %
0 2 20 1 10 3 30
1 2 20 2 20 3 30
2 3 30 5 50 3 30
3 3 30 2 20 1 10
Figure 1: Comparison of dye penetration among the three studied groups
Figure 2: Digital photograph by Figure 3: Digital photograph by

stereomicroscope showing score-0 dye stereomicroscope showing score-1 dye
penetration (Amalgam) penetration (Nano ceramic (Ceram.X))
Figure 4: Digital photograph by Figure 5: Digital photograph by

stereomicroscope showing score-2 dye stereomicroscope showing score-3 dye
penetration (Compomer (Twinky star) group) penetration (Compomer (Twinky star) group)

J Bagh College Dentistry Vol. 24(2), 2012 Oral health status among
Oral health status among a group of pregnancy and

lactating women in relation to salivary constituents and
physical properties (A comparative study)
Zinah M. Taqi Issa, B.D.S. (1)
Sulafa K.El-Samarrai, B.D.S., M.Sc., Ph.D. (2)
ABSTRACT
Background: The physiological and hormonal changes during lactating and pregnancy may affect dental and
gingival health conditions. The aims of this study were to investigate the occurrence and severity of both dental
caries and periodontal diseases among these women in relation to different salivary variables and constituents
Materials and Methods: A study group representing 30 lactating mothers whose infants were 4-6 months of age, and
30 pregnant women in the third trimester of pregnancy. Their age was 20-21 years. The control group comprised 30
married non-pregnant nulliparous women. Diagnosis and were recording of dental caries according to the WHO
(1987)criteria and GI, PlI according to the Löe and Sillness (1964), CI according to the Ramfjord, probing pocket
depth according to the Carranza et al, 2002. Stimulated salivary sample was collected according to the Tenovuo
&Lagerlof. The average salivary flow rate was measured from total volume, and the pH was determined using the pH
meter. Salivary samples were chemically analyzed for the detection of electrolytes (Ca and PO4), and
immunoglobulin (IgA), in addition to lysozyme enzyme.
Results: The total mean value of dental caries were recorded to be the highest among pregnant group followed by
lactating then control with statistically no significant difference (P> 0.05). Concerning the plaque index, gingival
index and calculus indices, they were recorded to be highest among pregnant group followed by lactating then
control with statistically no significant difference (P> 0.05). Regarding to pH, the control group showed the highest
value while the pregnant group exhibited the lower one with highly significant differences was recording between
groups P=0.000. The flow rate showed no significant difference between groups. No clinical loss of attachment was
seen between the groups. Calcium ions showed a high concentration in saliva of the lactating group compared to
the other two groups with highly significant differences P=0.01. Phosphorous ions showed a high concentration in
saliva of the lactating group compared to the other two groups with statistically no significant difference (P> 0.05).
Regarding salivary lysozyme the highest value was recorded among the pregnant group, while the lowest value was
recorded in the control with statistically no significant difference (P >0.05). The same result was seen for salivary IgA
but with a statistically significant difference (P <0.05).
Conclusion: The severity of dental caries and gingival inflammation were the highest among pregnant group
compared to the other two groups. This may related to the changes in the salivary pH and constituent during
pregnancy.
Keywords: lactating, pregnancy, dental caries, oral health status, salivary pH, salivary flow rate, salivary buffer,
calcium, phosphorous, lysozyme enzyme, IgA. (J Bagh Coll Dentistry 2012;24(2):155-159).
INTRODUCTION
Pregnancy and lactation are physiological statuses Other studies were conducted investigating
considered to modify metabolism in animals (1). changes in salivary variables (flow rate, pH and
Both require that numerous physiological buffer capacity) as well as salivary constituents as
adaptations must be made by the maternal electrolytes, immunoglobulin and hormonal
organism, to ensure that all the needs of the changes during pregnancy. These were correlated
growing fetus are met and that her own vital with oral and dental health, and a controversy in
functions are maintained (2). Changes occurring the result was noticed (4, 11, 13-15). On other hand
during pregnancy in women are well documented only one Iraqi study was able to be found
but less is known about lactation (3). These regarding salivary calcium during lactation (16).
changes were reported to have an impact on oral The aim of this study was to investigate oral
heath as well as dental health. Studies reported an health status in relating to salivary variables and
increase in gingival inflammation and caries – constituents among lactating and pregnant groups.
experience during pregnancy (4-12). Hormonal and
physiological changes continue during lactation, MATERIALS AND MATHODS
however there are limited studies investigating The sample taken in this study was 90 women
dental and gingival health status among lactating divided into three groups; each group is composed
women. of 30 volunteers; a first study group representing
lactating mothers whose infants were 4-6 months
(1) MSc student department of pediatric and preventive of age and the second group was pregnant women
dentistry, college of dentistry, University of Baghdad. in the third trimester of pregnancy. Each of them
(2) Professor, department of pediatric and preventive dentistry,
college of dentistry, University of Baghdad.
were 20-21 years old primiparous mothers. The

control group comprised 30 married non-pregnant supernatant was separated by micropipette and
nulliparous women; these women were age was divided into three portions, stored at (-20°C)
matched with the study group. Subjects should be in a deep freeze till being assessed in the Teaching
without any medical disease and no history of Laboratories of the Medical City Hospital.
smoking. Dental examination was done after Data process and analysis were done by using
collection of salivary sample. The examination of the Statistical Package for Social Sciences (SPSS
dental caries was conducted according to the version 17). Statistical tested used in this study
criteria of WHO(17). Oral examination was carried were; analysis of variance (ANOVA), least
out using plane mouth mirror and dental explorer. significant difference (LSD) test, were used to test
The collection of stimulated salivary samples was the difference between variable, Paerson‫ۥ‬s
performed following assesment of dental plaque correlation coefficient were all applied to see if
under standard condition following instruction there is any correlation between variables. The
cited by (18). Each individual was asked to chew a confidence limit was accepted at 95% (P < 0.05).
piece of Arabic gum (0.5-0.7 gm) for one minute
all saliva was removed by expectoration, chewing
was then continued for five minutes with the same RESULTS
piece of gum and saliva collected in a sterile Table 1 demonstrates the mean values and
screw capped bottle. Salivary pH was measured standard deviations of caries- experience
using an electronic pH meter and flow rate of according to DMFS/DMFT indices among study
saliva was expressed as milliliter per minute (ml / and control groups. Results showed that there no
min). The salivary samples were then taken to the statistically significant differences between three
laboratory for biochemical analysis. Samples were groups.
centrifuged at 4000 rpm for 30 minutes; the clear
Table 1: Caries – Experience (Mean and Standard Deviation) among Study and Control Groups.
DS MS FS DMFS DMFT
Groups
Mean±SD Mean±SD Mean±SD Mean±SD Mean±SD
Lactating 1.33±2.83 1.37±4.25 0.53±0.99 3.23±6.19 1.060±2.12
Pregnant 1.83±3.04 1.60±3.96 0.80±1.44 4.23±5.94 1.70±2.10
Control 1.10±2.95 0.83±1.89 0.27±0.63 2.20±3.71 0.996±1.35
Table 2 reveals the mean values of plaque, control. Salivary flow rate mean value was the
calculus and gingival indices among study and highest in the pregnant group compared to other
control groups. For the three indices statistically groups, statistically no significant difference was
no significant differences were recoreding noticed between the three groups (P >0.05).
between the three groups (P >0.05). Regarding the buffer capacity, results showed a
The correlations coefficients between plaque highest value among the control group with
and calculus indices with the gingival index statistically highly significant differences between
among the three groups showed a positive them.
statistically significant correlation between plaque In general no significant correlations were
index and gingival index in the control and recorded between caries-experience with salivary
lactating groups (r = 0.456, P <0.05). No variables among the three groups, except for the
correlation was seen between gingival index and salivary flow rate; a negative significant
plaque index in the group of pregnancy. Results correlation with DMFS in group of lactating
also showed that gingival index is not correlated women was noticed (r=-0.384 P=0.036). Also no
with calculus index in all groups. significant correlations were recorded between
Table 3 presents pH values, rates of secretions plaque and gingival indices in addition to calculus
of stimulated saliva and buffer capacity among index with salivary variables among the three
study and control groups. Concerning pH, the groups, except for the salivary pH; a positive
control group showed the highest value while the significant correlation was seen with gingival
pregnant group exhibited the lower one; a index (r=0.363, P= 0.048) and a negative
statistically significant difference was noticed significant correlation was seen in flow rate with
between the three groups. When the least calculus index in the lactating group (r=-0.459, P=
significant differences test was applied the 0.011).
statistically highly significant differences were Table 4 shows the mean concentration values
present in pH value between the pregnant group of salivary electrolytes (calcium and
with the control, and the lactating group with phosphorous), salivary lysozyme and IgA and

standard deviation among different groups. statistically not significant (F=0.355, P=0.702).
Calcium ions showed a high concentration in Regarding salivary lysozyme the highest value
saliva of the lactating group compared to the other was recorded among the pregnant group, while
two groups, difference between the study and the lowest value was recorded in the control with
control groups was statistically highly significant statistically no significant difference (P >0.05).
(F=80.080, P=0.01) . Phosphorous ions showed The same result was seen for salivary IgA but
the highest concentration in saliva of the lactating with a statistically significant difference (P
group compared to the other two groups, <0.05).
difference between the three groups was
Table 2: Plaque Index, Gingival Index, and Calculus Index (Mean and Standard Deviation)
among Study and Control Groups
PlI GI CI
Groups
Mean±SD Mean±SD Mean±SD
Lactating 1.230± 0.28 1.276± 0.28 0.009± 0.02
Pregnant 1.135± 0.29 1.340± 0.31 0.020± 0.06
Control 1.195± 0.37 1.252± 0.31 0.003± 0.01
Table 3: Salivary (pH), Flow Rate and Buffer effect (Mean and Standard Deviation) among
study and control groups.
pH Flow rate ml/min Buffer capacity
Groups
Mean±SD Mean±SD Mean±SD
Lactating 7.252* ± 0.363 0.993±0.321 5.163**± 0.961
Pregnant 7.000 ± 0.358 1.230±1.003 4.315± 0.452
Control 7.420 ± 0.304 0.900± 0.303 6.835± 3.073
Table 4: Salivary Electrolytes (Calcium & Phosphorous), salivary lysozyme and IgA (Mean and
Standard Deviation) among Study and Control Groups.
Ca ion mg/dl PO4 mg/dl Salivary Lysozyme (ng/ml) Salivary IgA (mg/dl)
Group
Mean ± SD Mean ± SD Mean ± SD Mean ± SD
Lactating 7.078±3.484 6.043±3.321 27.30±18.093 25.75±7.935
Pregnant 1.132±0.085 5.512±2.388 29.86±23.431 36.22±22.721
Control 1.652± 0.202 6.019±2.485 26.54±16.155 25.29±1.002
F=80.08 F=0.355 F=0.239 F= 5.925
Statistical test
P=0.000 P=0.702 P=0.788 P=0.004
DISCUSSION increase in salivary calcium concentration in

Although statistically not significant the highest lactating women may be attributed to the
value of the DMFS was recorded among pregnant temporary demineralization of the maternal
women followed by lactating then the control. skeleton that appears to be the main mechanism
This finding is not difficult to explain, pregnancy by which lactating women meet these calcium
is associated with many psychological and requirements (20). On the other hand a decrease in
stressful events that in turn lead to more self the salivary calcium concentration in pregnant
neglect and change of dietary habits, as the group was seen which may be related to hormonal
pregnancy itself is accompanied by an increase in fluctuation (21). Progesterone relaxes the smooth
appetite with frequent snacking on candy or other muscle cells of uterus and other organ such as
caries promoting foods (19). The elevation in the gastrointestinal tract, resulting in slowing of the
severity of dental caries seen by the present study gastrointestinal tract during pregnancy and
among pregnant, may be related to changes in the increases the absorption of several nutrients, most
salivary physical properties involving the flow notably iron and calcium. The same explanation
rate, as well as, the buffering capacity and pH. of calcium concentration reduction in pregnant
The lowest value of buffer capacity and pH were women could be applied for phosphorus as
recorded among pregnant group, this may phosphorus absorption goes side by side with
responsible to high caries experience. The calcium in the gastrointestinal tract (22).

The soft and hard tissues of the oral cavity are control and prevent dental caries as well as
under the protection of both non-specific and periodontal diseases.
specific immune systems. Their function is to
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Scientific Journal Published by the

College of Dentistry – University of Baghdad

Vol. 24 No. 2 2012

National Members International Members

Board of editorial consultants:

v Instructions for the Authors

Histological evaluation of osseointegration around titanium implants in thyroidectomized rabbits

Prevalence of pulp stone (Orthopantomographic-based). Zainab H. Al-Ghurabi, Areej A. Najm

Oral and Maxillofacial Surgery and Periodontology

Orthodontics, Pedodontic, and Preventive Dentistry

Effect of different metal surface treatments and

INTRODUCTION The actual bonding mechanism of metal to resin

Figure 2: Application of metal primer to

For third subgroups, the sample was treated first

Each sample was thermocycled for 3000 cycles in

Figure 4: Application of Metal Primer II for

For the light cure acrylic resin the sheets of

4. Pesun S, Mazurat R. Bond strength of acrylic resin to

Comparison of certain mechanical properties including

INTRODUCTION These materials generally replace the metal, and

Figure 1: Cropped picture showing a void in

Figure 4: Samples showing cracks in the area

Figure7: Stress strain curve of test group A

Figure 5: Propagation of a crack leads to an

A comparison of the retention of complete denture bases

Table 1: Means and standard deviation of Group A

Table 2: ANOVA and LSD of group A

Group A Mean Difference (I-J) Std. Error Sig.

Table 3: Means and SD of group B (deep palatal vault)

Table 4: ANOVA and LSD of group B

Group B Mean Difference (I-J) Std. Error Sig.

Table 5: Means and standard deviation of Group C

Table 6: ANOVA and LSD of Group C

Group C Mean Difference (I-J) Std. Error Sig.

Figure 1: Strain gauge force tranducer Figure 2: Physiological impression of pps

Figure 5: The patient during testing procedure

An evaluation of the use different techniques of the

Table 1. Descriptive statistics of the groups differences in methods of measurement of coronal

An evaluation of apical microleakage in roots filled with

The effect of two types of disinfectant on shear bond

The same specimen groups for viscogel material.

groups of viscogel material for surface

Immunohistochemical detection to evaluate the biological

INTRODUCTION Fibronectin is a large adhesive glycoprotein high-

Signaling Domains and Their Associated Transcripts

Figure 1: Conventional radiographic Figure 2: Positive DAB stain

Figure 4: View for positive

Figure 5: Immunohistochemical view for Figure 6: High magnification view of

Figure 7: Immunohistochemical view of Figure 8: View for positive

Figure 11: Thread view of titanium

Evaluation of 900 mhz mobile phone effects on palate and

and stained with Hematoxylin and eosin .All

Histological and immunohistological findings

Figure 6: positive reaction of CD34 in dental

Figure 11: tooth germ showed odontoblast

At 18th day I.U.L

Figure 13: Cross section in primitive mouth

Chronological ِage estimation in adolescent and young

INTRODUCTION Therefore developing 3rd molar is the only

MATERIALS AND METHODS

16. Tanner JM, Whitehouse RH, Marshall WA, Healy

Diagnosis of the angular hyperkeratotic lesions and the

Table 1: The classification of the diagnoses of the angular hyperkeratotic lesions