Scientific Journal Published by the

College of Dentistry – University of Baghdad

Vol. 23 No.3 2011

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. Khulood Al-Safi MSc, PhD Prof. J. L. Gutmann D.D.S., Ph.D.(USA)
Prof. Dr. Adel Farhan MSc Prof. Dr. M. Goldberg PhD (France)
Prof. Dr. Zainab Al-Dahan MSc
Prof. Dr.Abbas Sabri M.Sc., PhD
Prof. Dr.Wasan Hamdi M.Sc, PhD
Assist. Prof. Dr. Fakhri Al-Qaisy 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
Assist. Prof. Dr. Akram Al-Huwaizi MSc, 6- Assist. Prof. Dr. Maha Shukri MSc
PhD
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
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
Comparison of bond strength in different levels of post space of fiber-reinforced post luted with
1 different resin cements. Ahmed F. Al-Jaff, Haitham J. Al-Azzawi

Evaluation and comparison of the effect of repeated microwave irradiations on some mechanical and
6 physical properties of heat cure acrylic resin and valplast (nylon) denture base materials. Ali AM,
Raghdaa KJ.

Cuspal deflection in premolar teeth restored with a Silorane and a Dimethacrylate-resin based
11 composite (A comparative study). Ayad M. Mahmoud Al-Obaidi, Inas I. Al-Rawi

Influence of dental cleansers on the color stability and surface roughness of three types of denture
17 bases. Hussam M Saied

Evaluation the effect of modified nano-fillers addition on some properties of heat cured acrylic denture
23 base material. Ihab NS, Moudhaffar M.

The effect of low shrinkage dental composite on the fracture strength of weakened premolar teeth (An
30 in vitro study). Rasshaa Izzat Suhail, Ali H. Al-Khafaji

Push out bond strength of different obturation systems (An in vitro study). Yasameen Hasan Motea Al-
37 Ani, Hussain F. Al-Huwaizi

Oral Diagnosis
Histological evaluation of intrabony defect repair induced by white ordinary portland cement
44 (WOPC). Atheer A.Ali, Shatha S. Mohammed

The prevalence of cervical carotid arteries stenosis and calcifications among sample of Iraqi diabetic
50 postmenopausal women detected by using Doppler sonography and digital dental panoramic
tomography. Baydaa H. Hussein Al- Saleem, Lamia H. AL-Nakib

Assessment of serum and salivary oxidative stress biomarkers with evaluation of oral health status in a
56 sample of autistic male children. Mayyadah H. Rashid, Raja H. Al-Jubouri

Histological study of the effect of eucalyptol oil vapours on the development of the palate and tooth
61 germ (experimental study on rats). Muhanad T. Jehad, Athraa Y. Al- Hijazi

ii
 Prevalence, sex distribution of oral lesions in patients attending an oral diagnosis clinic in
67 Sulaimani University. Shanaz M. Gaphor, Mustafa J. Abdullah

The study of oral manifestations, oxidative stress marker and antioxidants in serum and saliva of
74 rheumatoid arthritis patients. Zahra K. Hadi, Tagreed F. Zaidan

Factors associated with parotid gland enlargement among poorly controlled Type II Diabetes Mellitus.
80 Zainab H. AL-Ghurabi, Ahlam A. Fatah, Omar F. Nafea, Warda L. Sleman, Qusay A. Fahad

Oral and Maxillofacial Surgery and Periodontology

Salivary enzymes as markers of chronic periodontitis among smokers and non smokers. Ayser N.
83 Mohammad

Experimental gingivitis in overweight subjects. Clinical and Microbiological study. Hadeel M.

88 Abbood Salman, Abdullatif A. Al-juboory

Prevalence of periodontal abscess among controlled and uncontrolled type 2 diabetic patients
92 (comparative study). Hayder R. Abdulbaqi

Oral hygiene and gingival health among overweight Iraqi school – age children (clinical
97 comparative study). Kadhim J. Hanau, Enas R. Naaom, Reem H. Majeed

Measurements of periodontal temperature & its comparison to the crevicular fluid flow in the
102 assessment of periodontal disease severity. Enas Sh Hamad, Maha Sh AL-Rubaie

Effect of super dental floss on oral hygiene in patients with fixed orthodontic appliances.
109 Mohammed A.H. Al-Bahadli

The effect of low-level laser on osseointegration of dental implants. Salah A. Issmaeel, Ali H. Abbas
112
Orthodontics, Pedodontic, and Preventive Dentistry
Caries experience of the first permanent molars among a group of children attending Pedodontics'
117 Clinic College of Dentistry. Ahlam Taha Mohammed

Oral hygiene and salivary immunoglobulin among acute lymphocytic leukemic patients undergoing
120 chemotherapy courses. Nadia Aftan Al-Rawi

Enamel defects in relation to nutritional status among a group of children with congenital heart
124 disease (Ventricular septal defect). Nidaa O. AL-Etbi, Wael S. Al-Alousi

Alveolar base and dental arch widths with segmental arch measurements in different classes of
130 malocclusions (A comparative study). Noor F.K. Al-Khawaja, Ausama A. Al- Mulla

The morphology and texture of Iraqi skeletal class II young adults (Cephalometric study). Raoof
137 R. Toma, Nagham Al-Mothaffar

Inter-arch tooth size discrepancy for Sulaimani population with class II malocclusion. Trefa M. Ali
144

iii
 The characteristic features of skeletal class III in Iraqi adult orthodontic patient. Wurood KH. Al-
149 lehaibi, Nagham Al-Mothaffar

A cephalometric lips analysis and its relation to other cephalometric measurements in Iraqi adult
156 individuals. Yasir R. Al-Labban

Soft-tissue cephalometric norms for a sample of Iraqi adults with class I normal occlusion in
160 natural head position. Zainab M. Kadhom, Mushriq F. Al-Janabi

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. 23(3), 2011 Comparison of bond strength

Comparison of bond strength in different levels of post

space of fiber-reinforced post luted with different resin
cements
Ahmed F. Al-Jaff B. D. S M.Sc. (1)
Haitham J. Al-Azzawi B. D. S M.Sc. (2)

ABSTRACT
Background: with the advent of new adhesive materials in dentistry, it has become important to measure regional
bond strength along the length of the canal of human teeth to assess the bond strength of resin cements to
endodontically treated teeth. This study aimed to investigate the effect of post space region (coronal, middle and
apical) and the mode of polymerization of the resin cement on the retention of the translucent fiber post to root
canal dentin, by using pull-out and push-out test methods.
Material and methods: extracted single rooted mandibular first premolars (n=32) were instrumented with ProTaper
universal system files (for hand use)and obturated with gutta-percha and AH26® root canal sealer. After 24hrs in the
incubator, post space was prepared to a depth of 8mm using FRCPostec drills no.3. . The prepared samples were
randomly divided into two main groups (16 samples each) according to the resin cement mode of polymerization
(Group A Dual-cure, RelyxU100), (Group B Self-cure, SpeedCem). Then each group was subdivided into two groups
(each with 8 samples) according to the test performed (A1: RelyxU100 and Push-out test, A2: RelyxU100 and pull-out
test, B1: SpeedCem and push-out test, B2: SpeedCem and pull-out test). Pull-out and push-out bond strength test
were measured using a universal testing machine to measure the bond strength.
Results: regarding the root region, the bond strength values decreased significantly from the coronal to the apical
region in both cements tested. For the mode of polymerization, no statistical significant difference was detected
between the dual- and self- polymerized resin cements.
Conclusions: the retention of fiber post was affected by the root region while the mode of polymerization didn’t
affect the bond strength. When measuring the bond strength of luted fiber post, the push-out test appears to be
more dependable than the conventional pull-out
Keywords: Fiber post, self-adhesive resin cement, push-out test, root region. (J Bagh Coll Dentistry 2011;23(3):1-5).

INTRODUCTION An adequate polymerization of luting agent is

Fiber posts have been introduced in the early
1990s to restore endodontically treated teeth with
an excessive loss of dentinal structure as an
alternative to cast post-and-core and metal
dowels. Because their elastic modulus is claimed
to be similar to that of the dentin, the risk of
vertical root fracture is expected to be reduced (1).
Furthermore, quartz or glass fiber posts (white or
translucent) can be used in situations of higher
(2)
elastic demands .
The adhesion of cements can be influenced by
the anatomical and histological characteristics of
the root canal, including the orientation of the
dentin tubules. Moreover, since the number of
tubules decreases from the crown to the apical
root (3), the response to acid etching and,
consequently, the dentin bonding can vary among
different areas of the same root canal (4).
(1) M.Sc student, Department of conservative dentistry,
college of dentistry, university of Baghdad.
(2) Professor, Department of conservative dentistry,
college of dentistry, university of Baghdad.
necessary to provide its mechanical properties that
clinically ensure post retention. Many current
resin luting agents polymerized through a dual-
curing process that requires light exposure to
initiate the reaction. It has been reported that the
mechanical properties of dual-cure type resin
agents improved after photo-activation compared
with chemical-activation alone (5). Dual-cure resin
cements are different in their handling
characteristics, compositions and properties (such
as polymerization ability, flexural strength and
hardness). These differences may have an effect
(6)
on the adhesion to root dentine substrate .
Bond strength can be determined by several
techniques, but the push-out bond strength test is
believed to provide a better estimation of the
actual bonding effectiveness than a conventional
shear bond strength test. Using a push-out
protocol, failure occurs parallel to the post–
cement–dentin interface, which is similar to the
clinical condition. Although the microtensile
method has also been applied to root dentin, the
push-out test seems to be more reliable because of
the absence of premature failures and the
variability of data distribution (7)

Restorative Dentistry 1
J Bagh College Dentistry Vol. 23(3), 2011
MATERIALS AND METHODS
Sample preparation. Thirty-two recently
extracted human mandibular first premolars,
predominantly extracted for orthodontic reason,
were selected, with patient’s age ranged from (18-
25) years old. The selection criteria for teeth
including the followings (8): Single straight root,
no visible root caries, no fractures, cracks or
external resorption on examination with 10X
magnifying eye lens and light cure device, and
diagnostic X-ray was taken to confirm the
existence of a single straight canal, fully formed
apex and no signs of internal resorption,
calcification or previous endodontic therapy. The
teeth were stored in 1% Thymol solution prior to
the study. The crown of each tooth was sectioned
perpendicularly to the long axis of the tooth at the
cementum-enamel junction, using diamond disc
under water coolant to obtain 14 mm length root.
Plastic test tube was used as a mold to hold the
specimens during root canal instrumentation,
obturation and post space preparation. The roots
were placed with the aid of dental surveyor
(Dentaurum, Germany) to position the long axis
of the roots parallel to that of plastic tubes.
Endodontic treatment. Root canal
instrumentation was performed using ProTaper
universal hand files (Dentsply, Maillefer) in
balanced force technique following
manufacturer’s instructions. Irrigation was
performed using 1ml of 2.25% NaOCl solution
after every change of file size throughout the
cleaning and shaping of the root canals. The
canals were then rinsed with 5ml of distilled water
as a final irrigation, dried with paper points,
canals were then filled with single cone technique
by gutta-percha for ProTaper F4 (Dentsply,
Maillefer) and AH26® root canal sealar. After
filling, the coronal surplus of the root filling was
removed with a heated excavator and the access
opening were sealed with temporary filling
material, and stored for 24hrs 37ºC in 100%
humidity.
Post space preparation. Filling material from the
cervical and middle thirds was removed with
pesos drills (Largo, Maillefer, Switzerland) and
the canal walls of each space was enlarged with
low speed FRC Postec®Plus drills No.3 (Ivoclar,
Schaan, Liechtenstein) under copious water
cooling, following the manufacturer’s
instructions, creating (8mm) deep post space
measured from the coronal end of the, keeping at
least 5mm of gutta-percha apically (9).
Post cementation. At this point, the samples were
randomly divided into two groups of 16 samples
each, depending on the resin cement’s mode of
polymerization (self-, dual-cured), then each
Restorative Dentistry
Comparison of bond strength
group are further sub-divided into two groups (8
samples each), according to the test performed.
Group A1: RelyxU100 tested with Push-out test.
Group A2: RelyxU100 tested with pull-out test.
Group B1: SpeedCem tested with push-out test.
Group B2: SpeedCem tested with pull-out test.
Group A1, A2:
Prior to cementation, the post space was
irrigated with 2ml of 2.5% NaOCl and then finally
irrigated with 2ml of distilled water and then dried
with paperpoint (F4). Before cementation
procedure, each post was marked at distance of
8mm from the apical end corresponding to the
post space preparation, in this way; the complete
seating of the post was verified (10). Equal parts of
base and catalyst were dispensed and mixed into a
homogenous paste with 20 sec., in accordance
with manufacturer’s instructions. After this, the
cement were placed inside the post space with the
aid of #40 lentulo spiral, and the post was inserted
and held, under a constant load of 4.5 Kg for 60
sec.(11), the excess cement was removed and
further polymerization of the resin cement was
performed for 20 sec. from occlusal direction
according to manufacturer’s instructions.
Group B1, B2
The procedure was the same as that of (A1,
A2), except that the SpeedCem resin cement was
allowed to auto-cured for 4 minutes according to
the manufacturer’s instructions.
Push-out bond strength test. The specimens
were embedded in a clear acrylic resin,
maintaining the post axis parallel to the wall of
diamond disc mounted on straight handpiece, the
cutting was made under heavy water flow.
From each specimen, 3 post/dentin sections
(cervical, middle, and apical) were obtained, each
2 in mm thick. The exact length of fiber post
segments in each section was measured using a
vernier (12).Then each slice was marked on its
apical side with indelible marker, to make sure
that the load will be applied in apico-coronal
direction due to the conical shape of the FRC Post
used in the study (11).
Push-out tests were performed by applying a
compressive load to the apical aspect of each
section via a cylindrical plunger mounted on
Universal Testing Machine (Tinius-Olsen,
Philadelphi) managed by computer software. The
load was performed at a cross head speed of 0.5
min/min until the post segment was dislodged
from the root slice (13). The maximum force
required to dislodge each post was recorded in N
and converted into Mpa. considering the bonding
surface area (mm²) of the post segment, post
diameters were measured on each segment of the
post/dentin section using Nikon metallurgical
2
J Bagh College Dentistry Vol. 23(3), 2011 Comparison of bond strength

microscope, and the total bonding area for each cements. A non significant difference is also
post segment was calculated using the formula of found between the middle and the apical regions
a conical frustrum (14): in both types of resin cements.

Π (R1+R2) )

Where R1 represent the coronal post radius,

represent the apical post radius and is the
thickness of the slice.
Pull-out bond strength test. Custom-made
plastic mold with internal dimensions of 2cm X
2cm and depth of 3cm was used. Parallelism
between post, canal and resin block was obtained
using a dental surveyor (CO). The acrylic resin
was extending to a level extending 1mm below
the coronal end of the root (10).
The pull-out test was performed by Universal
Testing Machine (Tinius-Olsen, Philadelphi) Figure 1: Bar chart showing the mean push-
managed by computer software at a crosshead out bond strength of the resin cements.
speed of 0.5 mm/ min and the load cell was set at
50 KG. The maximum force required to dislodge 2. Pull-out test.
each post was recorded in N and converted into Figure 2 shows that the mean pull-out bond
Mpa. The bonding surface area was calculated by strength for RelyxU100 was higher than for
the same formula used for the push-out test SpeedCem resin cement.
specimens’ (14). In the second analysis, the mode of
polymerization showed a non significant
influenced on the bond strength, in both push-out
RESULTS and pull-out tests (P=0.067).
All statistical analysis was performed using
commercially available software (SPSS for
Windows) version 15. The level of significance
was 0.05
1. Push-out test.
The mean push-out bond strength of resin cements
in different root regions are shown in (Figure 1). The
mean push-out bond strength values for RelyxU100
were higher than that of SpeedCem in the all three
regions. The coronal region in both resin cements had
higher mean push-out bond strength values, followed
by the middle and the apical regions.
In the first analysis, one-way ANOVA test
revealed that the bond strength was significantly Figure 2: Bar chart represents the mean
affected by the different regions of the post space, pull-out bond strength values.
with reduction from cervical to apical region.
With RelyxU100, a statistically significant difference
(P<0.05) were found among all three thirds. With
DISCUSSION
The success of fiber post-and-core restorative
SpeedCem resin cement, highly significant difference
procedures depends, in part, on the cementation
(P<0.01) were found among all regions. It was
technique used to create a link between the post
determined by the LSD multiple comparison test that
and root canal dentin (15). The objective of
(TAB), in RelyxU100 there is a significant
developing this kind of resin cement was to
difference (P<0.05) in mean push-out bond
reduce technique sensitivity and make handling
strength between the coronal and the apical
simpler without scarifying good adhesion to tooth
regions. A significant difference (P<0.05) exist
surface, compared to two or three steps. The
between the coronal and apical regions of the
present study investigates the bond strengths of
SpeedCem. A non significant difference in mean
various resin cements to root canal dentine using a
push-out bond strength (P>0.05) between the
push-out model. Push-out tests result in a shear
coronal and middle regions in both types of resin
stress at the interface between dentine and cement

Restorative Dentistry 3
J Bagh College Dentistry Vol. 23(3), 2011
as well as between post and cement; this is
comparable with the stresses under clinical
conditions. The push-out design is characterized
by polymerization stresses that would happen in
the clinical situation (14).
Several factors may contribute to the
reduction in the bond strength from coronal to
apical direction. Some of these factors are
inherited to the root dentin composition, and
others are related to the restoration techniques
used (16). The structure of dentin is an important
factor that should be taken into account in term of
bonding (17). The bond strength in different post
space levels seems to be influenced by tubule
density and area of a tubular dentin. According to
previous study (18), as the number of dentinal
tubules decreases, mainly from coronal to the
apical thirds of the post space dentin, the
difference in the tubule density may explain why
the strongest adhesion occurred in the most
coronal sections.
Also, lower bond strength values in the apical
region may be related to factors associated with
accessibility and direct viewing to the operative
site. Because the apical part of the canal is the
least accessible part of the root canal; certain
factors such as discontinuous area covered by
remnants of gutta-percha and endodontic sealer
may hamper the penetration of the resin cement
into the dentinal tubule. This agrees with (1) who
stated that it’s crucial to obtain a “clean” surface,
simply because small residue can reduce the area
of surface available for post bonding.
Additionally, for the dual cure resin cement,
another possible explanation is that the decreasing
effect of light curing at greater distance from the
light source might be responsible for the lower
bond strength apically (11). Since the higher bond
strength value of resin cement is related to higher
degree of monomer conversion and the degree of
conversion decrease when the distance from the
light source increased (19). And because of that in
the deep part of the post space, the light
penetration is limited which may result in lower
degree of conversion of polymerized
dimethacrylate resin monomer, consequently,
lower bond strength values recorded in the apical
region of the root canal.
An adequate polymerization of the luting
agent is necessary to provide its mechanical
properties, which clinically ensure post retention.
The polymerization contraction may affect the
dentin-adhesion interface at different levels,
depended on the Configuration factor (C-factor).
In intra-coronal restorations, the C-factor is very
high, this is because there is a large area of resin
cement bonded to dental substrate and endodontic
Restorative Dentistry
Comparison of bond strength
post, and there is little free area to allow for
polymerization contraction (20). It has been
reported that the light exposure demanded to start
the polymerization reaction on the dual-cured
cements increases the velocity of the
polymerization, leading to higher stress along the
cavity, because the material could not flow to
relief the polymerization stress. On the other
hand, slower setting materials may reduce stresses
at the bonding interface because the slow setting
allows flow of the material to relive
polymerization stress (21).
Direct comparison between pull-out and push-
out test for the adhesive cements tested showed
that push-out bond values were higher than those
of pull-out. This is probably due to that larger
specimens seem to contain more defects or stress
raisers such as air bubbles, phase separation, and
surface roughness than smaller specimens at the
bonded interface or within the substrate. If the
bonding interface is not uniform, this will lead to
non-uniform stress distribution, consequently, a
crack line may develop which creates a stress
concentration that will be dissipated by rapid
crack propagation causing failure within the
substrate. This may initiate fracture at the defect,
resulting in lower tensile bond strength that might
be measured in smaller samples this is agreed
with (22). On the other hand, high bond strength
value for push-out test may be attributed to that
the smaller specimens contains a lower number of
internal defects, this is reported to produce a more
homogenous stress distribution and less cohesive
type of failure (23). Also, root slicing, which is
employed in the methodology of the test, was
justified by the intention to favor stress uniformity
by loading smaller-sized specimens. In addition,
sectioning allowed the differentiation of the
bonding conditions existing at different root levels
and providing useful measurements with limited
variability (24).
REFERENCES
(1) Zicari F, Eduardo Couthino, Jan De Munck, Andr´e
Poitevin, Roberto Scotti, Ignace Naert, Bart Van
Meerbeekb. Bonding effectiveness and sealing ability
of fiber-post bonding. Dent Mater 2008; 24(7):967-
77.
(2) Vichi A, Ferrari M, Davidson CL. Influence of
ceramic and cement thickness on the masking of
various types of opaque posts. J Prosthet Dent 2000;
83(4):412–7.
(3) Mannocci F, Pilecki P, Bertelli E, Watson T. Density
of dentinal tubules affects the tensile strength of root
dentin. Dent Mater 2004; 20(3):293–6.
(4) Carrigan PJ, Morse DR, Furst ML, Sinai JH. A
scanning electron microscopic evaluation of human
dentinal tubules according to age and location. J
Endod 1984; 10(8):359–63.
4
J Bagh College Dentistry Vol. 23(3), 2011 Comparison of bond strength

(5) Hofmann N, Papsthart G, Hugo B, Klaiber B. autopolymarized adhesive systems to root dentin
Comparison of photo-activation versus chemical or using translucent and opaque fiber-reinforced
dual-curing of resin based luting cements regarding composite posts. J Prosthet Dent 2007; 97(3): 165-72.
flexural strength, modulus and surface hardness. J (21) Bouillaguet S, Troesch S, Wataha JC, Krejci I, Meyer
Oral Rehabil 2001; 28(11):1022–8. J-M, Pashley DH. Microtensile bond strength between
(6) Aksornmuang J, Nakajima M, Foxton RM, Tagami J. adhesive cements and root canal dentin. Dent Mater
Mechanical properties and bond strength of dual-cure 2003; 19(3):199-205.
composites to root canal dentin. Dental Mater 2007; (22) Goracci C, Grandini S, Bossu M, Betrelli E, Ferrari
23(2): 226-34. M. Laboratory assessment of the retentive potential of
(7) Goracci C, Tavares AU, Fabianelli A, Monticelli F, adhesive posts: A review. J Dent 2007; 35(11): 827-
Raffaelli O, Cardoso PC, Tay F, Ferrari M. The 35.
adhesion between fiber posts and root canal walls: (23) Abdalla AI. Microtensile and tensile bond strength of
comparison between microtensile and push-out bond single-bottle adhesives: a new test method. J Oral
strength measurements. Eur J Oral Sci 2004; Rehabil 2004; 31(4): 379-84.
112(4):353-61. (24) Goracci C, Tavares AU, Fabianelli A, Monticelli
(8) Kosti E, Lambrianidis T, Economides N, Neofitou C. F, Raffaelli O, Cardoso PC, Tay F, Ferrari M. The
Ex vivo study of the efficacy of H-files and rotary adhesion between fiber posts and root canal walls:
NiTi instruments to remove gutta-percha and four comparison between microtensile and push-out bond
types of sealer. J Endod Res 2005; 39(1): 48-54. strength measurements. Eur J Oral Sci 2004; 112(4):
(9) Perdigão J, Gomes G, Lee IK. The effect of silane on 353-61.
the bond strengths of fiber posts. Dent Mater 2006;
22(8):752-8.
(10) D’Arcangelo C, Maurizio D’Amario, Francesco D
Angelis, Simone Zazzeroni, Mirco Vadini, and Sergio
Caputi. Effect of Application Technique of Luting
Agent on the Retention of Three Types of Fiber
reinforced Post Systems. J Am Assoc Endod 2007;
33(11):1378-82.
(11) D’Arcangelo CS, Zazzeroni M, D’Amario M, Vadin
F, De Angelis O, Trubiani S, Caputi. Bond strengths
of three types of fibre-reinforced post systems in
various regions of root canals. J Endod J 2008;
41(4):322-8.
(12) Akgungor G, Akkayan B. Influence of dentin bonding
agents and polymerization modes on the bond
strength between translucent fiber posts and three
dentine regions within a post-space. J Prosthet Dent
2006; 95(5):368–78.
(13) Vano M, Cury AH, Goracci C Chieffi N, Gabriele M,
Tay FR, Ferrari M. The effect of immediate versus
delayed cementation on the retention of different
types of fiber post in canals obturated using a eugenol
sealer. J Endod 2006; 32(9): 882–5.
(14) Bitter K, Meyer-Lueckel H, Priehn K, Kanjuparambil
JP, Neumann K, Kielbassa AM. Effect of luting agent
thermocycling on bond strength to root canal dentin.
Int Endod J 2006c; 39(10): 809-18.
(15) Radovic I, Mazzitelli C, Chieffi N, Ferrari M.
Evaluation of the adhesion of fiber posts cemented
using different adhesive approaches. Eur J Oral Sci
2008; 116(6): 557–63.
(16) Lopez G C, Ballarin A, Baratieri LN. Bond strength
and fracture analysis between resin cements and root
canal dentin. Aust Endod J 2010:1-7.
(17) Bitter K, Noetzel J, Neumann K, Kielbassa AM.
Effect of silanization on bond strengths of fiber posts
to various resin cements. Quintessence Int 2007;
38(2):121-8.
(18) Ferrari M, Mannocci F, Vichi A, Cagidiaco MC, Mjör
IA. Bonding to root canal; structural characteristics of
the substrate. Am J Dent 2000; 13(5):255-60.
(19) Kim YK, Kim SK, Kim KH, Kwon TY. Degree of
conversion of dual-cured resin cement light-cured
through three fibre posts within human root canals: an
ex vivo study. Int Endod J 2009; 42(8), 667–74.
(20) Mallmann A, Jacques LB, Valandro LF, Muench A.
Microtensile bond strength of photoactivated and

Restorative Dentistry 5
J Bagh College Dentistry Vol. 23(3), 2011 Evaluation and comparison

Evaluation and comparison of the effect of repeated

microwave irradiations on some mechanical and physical
properties of heat cure acrylic resin and valplast (nylon)
denture base materials
Ali AM,BDS, MSc (1)
Raghdaa KJ BDS, MSc, PhD (2)

ABSTRACT
Background: Microwave irradiation has been considered for denture sterilization/disinfection instead of chemical
solutions since it has no expiration date and does not induce resistance to the microorganisms. The aim of this study
was to evaluate the effects of repeated microwave disinfection on heat cure and valplast (nylon) denture base
materials in some mechanical and physical properties.
Material and method: A total No. of 320 specimens (80 maxillary denture bases and 240 specimens) were prepared
in this study, then divided into two main groups according to the type of material used (heat cure resin and valplast
resin).Each main group was subdivided into four subdivisions according to the type of test used (Transverse strength
test, Surface hardness test, Surface roughness test, and fitness test), for each test 40 samples were divided into four
groups according to the number of cycles of microwave disinfection that were applied (control, 1 microwave cycle,
3 microwave cycles, and 7 microwave cycles). The term cycle refer to 3min of microwave disinfection at 680 watt.
Each specimen was disinfected(subjected to one cycle) one time per a day then transferred to container contain
distilled water until another cycle applied in the next day.
Result: The repeated microwave irradiation of heat cure and valplast specimens showed slight but no significant
decrease in transverse strength, shore D hardness, and surface roughness. The results of the fitness of denture base
materials to stone cast showed an improvement in the fitness of heat cure and valplast denture base materials after
the first microwave cycle, and no further improvements in the fitness were taken place after repeated microwave
disinfection.
Key Word: valplast (nylon), microwave irradiation, mechanical and physical properties. (J Bagh Coll Dentistry
2011;23(3):6-10).

INTRODUCTION
Polymethylmethacrylate (PMMA) is a
derivative of acrylic acid, referred to us as acrylic
resin, introduced for use in dentistry and it
became the most reliable material for denture
construction(1). The development of polymer
chemistry produce alternative materials to PMMA
such as polyamides(nylon plastics), acetal resins,
epoxy resins, polystyrene, polycarbonate
resin…etc. all these resins are suited for
thermoplastic processing(2).
A nylon, that is suitably stiffened, could be
extremely useful in the treatment of those patients
for whom acrylic prostheses are not suitable. This
would include patients who demonstrate repeated
fracture of dentures and those that show tissue
reactions of a proven allergic nature.
The chief advantage of nylon lies in its
resistance to shock and repeated stressing (3) .
Removable prostheses may be potential sources of
infection since the accumulation of deposits, such
as food debris, stains and microbial plaque on
denture surface may result in inflammatory
changes to the oral mucous. (4).
(1) Assistant Lecturer University of Baghdad, College of
dentistry, Prosthodontics department.
(2) Assistant Professor University of Baghdad, College of
dentistry, Prosthodontics department.
Restorative Dentistry
The available disinfection methods for
complete and partial dentures are still
controversial because they may alter some
material properties and clinical features (5).
For instance, alcohol-based disinfectants
reduce the flexural strength of non-crosslinked
denture base acrylic resins (6). Surface alteration
may occur by continuous use of some disinfection
methods, e.g., staining (by soaking in
chlorhexidine) or bleaching (by soaking in sodium
hypochlorite) (7).
Microwave irradiation has been considered
for denture sterilization/disinfection instead of
chemical solutions because it requires no special
storage, has no expiration date and does not
induce resistance to Candida albicans(8).This
study designed to evaluate the effect of repeated
microwave radiation on some physical and
mechanical properties of different types of
denture base materials.
MATERIALS AND METHOD
Each main group was subdivided into four
subdivisions according to the type of test used
(transverse strength, surface roughness, surface
hardness and fitness tests), for each test 40
samples were divided into four groups according
6
J Bagh College Dentistry Vol. 23(3), 2011
to the number of cycles of microwave disinfection
that were applied (control, 1MW-cycle, 3MW-
cycles, and 7MW-cycles).The term MW-cycle
refer to 3min of microwave disinfection at 680
watt, each specimen was disinfected(subjected to
one cycle) one time per a day then placed in
distilled water until another cycle applied in the
next day. In case of control group, no microwave
disinfection were applied
Table 1: Some of the materials used in the
study
Material Manufacturer
Heat-cured resin for Powder&liquid. Vertex,
1
denture. Holland
Valplast (nylon)
2 Nylon grains. USA
denture base
.
Preparation of specimens for surface
roughness, hardness, and transverse strength
tests.
Metal patterns were constructed by cutting the
stainless steel plates with the dimensions of
(65mm x 10mm x 2.5mm) length, width,
thickness respectively (9).
Mould preparation for heat-cured resin specimens:
The conventional flasking technique for complete
dentures was followed in preparation of the
mould.
Proportioning and mixing of the acrylic
All the materials were mixed and manipulated
according to manufacture instructions
Packing and curing of heat cure resin
The packing process was performed while the
acrylic was in dough stage. Curing was carried
out by placing the clamped flask in a water bath
and processed by short curing cycle 90min at
74C° then temperature was increased to the
boiling point 100°C for 30 minutes(9).
Finishing, Polishing and conditioning
All the specimens were finished and polished by
the same investigator as follows:
Silicon carbide grit papers starting with grade
120,240,320,400 and 500 were used in sequence
during finishing procedure with continuous water
cooling. The accuracy of the dimensions was
verified with a vernier at three locations of the
specimen. Polishing was accomplished by using
Tripoli compound with a dry rag wheel in a lathe-
polishing machine. Water was used during
polishing to avoid excessive heat, which may lead
to distortion of the specimens.
All the tested specimens were conditioned in
distilled water at 37C° for 48 hours before they
were tested (9).
Restorative Dentistry
Evaluation and comparison
Mould preparation for valplast resin:
The same as in heat cured mould preparation but
with wax sprues were prepared - major sprues
with 6-8mm in diameter, minor sprues 2-4mm in
diameter- and attached to selected areas from one
side of the metal pattern (10) and as in (fig1). Then
the upper portion of the metal flask was
positioned on top of the lower portion and filled
with stone, vibration was done to get rid of the air
bubbles. Stone was allowed to harden before the
metal flask was opened.
Figure 1: Wax sprues attached to metal
patterns for valplast resin
Wax elimination was performed using boiling
water then metal flask was opened, the metal
patterns were removed from the mould carefully.
Procedure of injecting the valplast denture base
material:
The procedure started with the heating cylinder
inserted into the slot present inside the electrical
furnace as shown in (fig.2) and the furnace was
allowed to warm up till it reaches the preset
heating which was 287°C, then the heating
cylinder removed from the furnace, then valplast
cartridge, metal disc and the short solid metal
cylinder inserted into the heating cylinder and left
inside the furnace for 11 minutes to allow the
granules inside the cartridge to melt.
Plunger
Heating
cylinder
Clamped
flask
Figure 2: position of heating cylinder before
injection procedure.
During that time the flask, that previously
preheated inside an oven set at 65°C, removed
from the oven and placed inside the injection unit
7
J Bagh College Dentistry Vol. 23(3), 2011
in horizontal position in its correct position with
the aid of the projection present at the base of the
injection unit. In this position the injection
opening was at the top surface of the flask.
The material was injected inside the flask by the
use of the manual injection unit the handle of the
injection unit was tightened until both springs on
the top side of the unit were closed to give a
pressure of 5 bars. After 5 minutes the pressure
was released and the flask is removed from the
injection unit and allowed for cooling at room
temperature.
Finishing, polishing and conditioning of the
specimens:
All the specimens were hand finished and
polished in the same manner as in heat cued
specimens
Microwave disinfection of specimens:
All the prepared specimens were submitted to
microwave radiation in order to be disinfected
(except the control groups of each material) and
as in the following way:
Each specimen was immersed in 150 ml of
distilled water inside a cup made of glass and
inserted inside a microwave oven which was set at
650 W for 3 min as shown in (fig.3) and that was
referred as a "disinfection cycle of microwave
irradiation"(11).
Figure 3: Specimen inside microwave oven
Mechanical and physical tests utilized to
examine properties
1- Transverse strength test
The transverse strength of specimens was
measured in air by three points bending on an
Instron 1122 Transverse testing machine. The
device was applied with a central loading plunger
and two supports with polished cylindrical surface
3.2mm in diameter placed 50mm apart. The test
were carried out with a constant cross head speed
of 5mm/ minute, the load was measured by a
compression load cell of maximum capacity of
500N.
The test specimens were held at each end of the
two supports, and the loading plunger placed
midway between the supports. The specimens
were deflected until fracture occurred. When
Restorative Dentistry
Evaluation and comparison
valplast specimens were tested, the specimens
were deflected till the specimen become as a U
shape; none of the specimens were fractured and
remained one piece
2-Surface hardness test
Surface hardness was determined using durometer
hardness tester from type shore D, (hardness
tester-TH 210, time group Inc. Italy) which is
suitable for acrylic resin material. The instrument
consists of blunt-pointed indenter 0.8mm in
diameter that tapers to a cylinder 1.6mm. The
indenter is attached to a digital scale that is
graduated from 0 to 100 units; measurements
were taken directly from the digital scale reading.
Ten measurements were done on different areas of
each specimen (the same selected area of each
specimen), and an average of ten readings was
calculated.
3- Surface roughness test
The profilometer device (Surface roughness tester
SRT-6210, England) used to measure the surface
roughness of the specimens, this device is
supplied with sharp stylus (surface analyzer)
made from a diamond to trace the profile of
surface irregularities.
At first the specimen was placed on a fixed and
stable base then the device adjusted in a way so
that the stylus just touch the surface of the
specimen, after that the stylus was traversed
toward the right direction along the specimen
surface for 11 mm length then the reading
appeared on the digital scale
Denture bases preparation for measuring the
fitness at the posterior palatal region.
Cast preparation
Eighty maxillary edentulous casts were prepared
from an edentulous silicon mold. The silicon mold
was poured with type IV stone mixed at a ratio of
25ml of water to 100gm of powder according to
manufacturer instructions. The cast was separated
from the mold after 45 min .The mold was left for
15 minutes to pour the second cast and so on. (12)
Record base preparation.
The record base was prepared by using a biostar
machine. The cast was placed on the biostar table
and dipped in the biostar beads just below the
borders; the biostar plate (2mm thickness, clear)
was placed in the pressure chamber. After waiting
for pressure evacuation, the cast was removed,
cutting, trimming and finishing for the plate using
biostar burs and sealed with wax on the cast.
8
J Bagh College Dentistry Vol. 23(3), 2011 Evaluation and comparison

Table 1: Descriptive data of transverse the whole length of the cast was 52mm. The base-
strength. cast sets were transversally sectioned with a
manual saw device (2 cuts per second) at the
Studied groups Mean SD. Min. Max. distal aspect of the second molar, anterior to the
Control 81.22 1.25 79.50 83.00 posterior palatal seal area (12).The measurement
H.C.A.

MW1 81.01 1.31 79.30 82.90 was done at the previously mentioned points by
MW3 80.88 1.19 78.70 82.70 using a travelling microscope(accuracy 0.01mm).
MW7 80.75 0.81 79.80 82.70
Control 71.63 1.79 68.90 73.70 Table 3: Descriptive data of surface
V.nylon

MW1 71.17 1.74 67.90 73.30 roughness test

MW3 70.44 1.46 67.80 72.10 Studied groups Mean SD. Min Max
MW7 70.13 1.49 67.10 72.00 Control 96.24 1.475 93.6 98.4

H.C.A.
MW1 96.22 1.450 94.4 98.6
Table 2: Descriptive data of surface hardness MW3 96.12 1.437 94.8 98.4
test. MW7 96.04 1.670 93.6 98.8
Control 54.00 1.600 51.6 57.6

V.nylon
Studied groups Mean SD. Min. Max MW1 53.76 1.239 51.6 55.2
MW3 53.52 1.012 51.6 55.2
Control 1.245 0.085 1.13 1.35 MW7 53.52 1.012 51.6 55.2
H.C.A.

MW1 1.220 0.078 1.10 1.32

MW3 1.212 0.080 1.10 1.33
Table 4: Descriptive data of mean gap spaces
MW7 1.210 0.079 1.10 1.33
at the posterior palatal region for valplast
Control 4.494 0.302 3.98 5.02
V.nylon

4.459 0.454 3.54 5.20

material
MW1
MW3 4.385 0.476 3.30 5.12 Materials Groups Mean SD
MW7 4.271 0.549 3.20 5.34
Control - (A) 0.16 0.01
Flask preparation for heat-cure denture bases Control - (B) 0.17 0.01
The cast with the record base was flasked in the Control - (C) 0.57 0.01
lower part of a traditional brass flask with stone Control - (D) 0.17 0.01
mixture. A separating medium was applied to the Control - (E) 0.15 0.01
investment and allowed to dry, and then the upper MW1 - (A) 0.14 0.01
part of the flask was assembled and filled with the MW1 - (B) 0.15 0.01
Valplast ( Nylon )

stone. The flask parts were separated after setting MW1 - (C) 0.55 0.01
of stone, the record base was removed, and a coat MW1 - (D) 0.15 0.01
of separating medium of fixed volume about 1ml. MW1 - (E) 0.14 0.01
was applied as a mold separator on the surface of MW3 - (A) 0.14 0.01
the stone and the cast. Curing, packing and MW3 - (B) 0.15 0.01
finishing steps were done in the same ways as MW3 - (C) 0.55 0.01
mentioned before. MW3 - (D) 0.15 0.01
Flask preparation for valplast denture bases MW3 - (E) 0.14 0.01
The same procedure as mentioned before for heat- MW7 - (A) 0.14 0.01
cure denture bases, but before the upper part of MW7- (B) 0.15 0.01
the flask was assembled wax sprues were MW7 - (C) 0.55 0.01
prepared into two designs(major and minor) and MW7 - (D) 0.15 0.01
attached to selected areas from one side of the MW7 - (E) 0.14 0.01
record base(10). Wax elimination was performed
using boiling water then metal flask was opened. RESULTS
The flask allowed for bench cooling. Mean values, standard deviation (SD), maximums
Injecting and finishing for valplast denture base (Max) and minimums (Min) of the tests result are
material, were done in the same ways mentioned presented in Table 1-4.
before. In general the results of the transverse strength,
Microwave disinfection of denture bases: surface hardness and surface roughness tests for
The same as described before in disinfection of heat-cured acrylic (H.C.A.) and valplast(V.nylon)
specimens for other tests. specimens showed that control group specimens
Sectioning and measuring of the base-cast sets: had the highest mean values while MW7 group
The location of the cutting line was 39mm from specimens had the lowest mean values. Two-
the anterior aspect of the base of the cast, where
Restorative Dentistry 9
J Bagh College Dentistry Vol. 23(3), 2011
way(ANOVA) test revealed a non significant
difference (P>0.05) between the different groups
of the same material while one-way (ANOVA)
showed a highly significant difference (P<0.01)
between H.C.A. and V.nylon specimens.
The results of the fitness test for heat cured
(H.C.A.) and valplast(V.nylon) denture base
materials showed that control group specimens at
point (c) had the highest mean values of gap
spaces while specimens of MW1, MW3 and
MW7groups had the lowest mean values of gap
spaces at either point(a) or point (e).
The results showed that too highly significant
differences at P<0.001 were found at all possible
comparisons at the same point of the same group
between H.C.A. and V.nylon denture base
materials.
For H.C.A. and V.nylon denture base materials,
there were significant differences between control
group and MW1 group at the same point of
measurement (a, b, c, d or e) for the same
material. There were no significant difference
between MW1, MW3 and MW7 groups at the
same point of measurement (a, b, c, d or e) for the
same material.
DISCUSSION
The results revealed that valplast (nylon)
specimens had lesser transverse strength, hardness
values and greater surface roughness than heat
cure acrylic resin specimens. This difference may
be due to the difference in their structural
formula(chemical composition),since the nylon
have polyamide linkage as a repeating unit that
make nylon have more flexibility and fracture
resistance than heat cure acrylic with ester linkage
with large crystals at the surface of the specimen.
The results showed that repeated microwave
irradiation had no significant effect on the
transverse strength, surface hardness, and surface
roughness of the heat cure and valplast resin
specimens despite of slight decrease in their
values. This may be attributed to the higher
polymerization temperature used for the denture
base material
The results for the fitness test showed that Heat
cure denture base material showed better fitness
(adaptation) than valplast denture base material at
the posterior palatal region. This may be due to
the difference in the chemical structure between
the two materials, since nylon properties are
affected by the amount of crystallinity. Nylon
shows high mold shrinkage as a result of their
crystallinity (13). The results showed that
microwave irradiation improved the fitness of the
heat cure and valplast denture bases after one
cycle of microwave disinfection and no further
Restorative Dentistry
Evaluation and comparison
improvements were shown after 3 or 7 cycles of
microwave irradiation. The improvement in the
denture base adaptation may be related to the
linear shrinkage that results from the residual
polymerization of the acrylic resin during
simulated microwave irradiation. In case of
valplast specimens linear shrinkage occurred
because of evaporation of interstitial polymer
matrix as a result of increasing in the water
temperature under the influence of microwave
radiation.
REFERENCES
1. Wilson HJ, Mansfield MA, Health JR, Spence S.
Dental technology and materials. 8th ed. Oxford: Black
well Scientific Publication; 1987. p.312-23.
2. Bortun C, Lakatose S, Sandu L, Negrutiu M, Ardelean
L. Metal-free removable partial dentures made of
thermoplastic materials. Temisora Med J 2006;56: 80-7.
3. Stafford GD, Huggett R, Mac Grcgor AR, Grahau J.
The use of nylon as a denture-base material. J Dent
1986; 14: 18-22.
4. John J, Gangadhar SA, Shah I. Flexural strength of
heat-polymerized poly methylmethacrylate denture
resin reinforced with glass, aramid or nylon fibers. J
Prosthet Dent 2001; 86: 424-427.
5. Asad T, Watkinson AC, Huggett R. The effect of
disinfection procedures on flexural properties of denture
base acrylic resins. J Prosthet Dent 1992; 68:191–5.
6. Rohrer R, Bulard B. Microwave sterilization. J Am
Dent Assoc 1985; 110:194-8.
7. Baysan A, Whily R, Write PS. Use of microwave
energy to disinfect a long-term lining material
contaminated with candida albicans or staphylococcus
aureus. J Prosthet Dent 1998; 79: 454-8.
8. Banting DW, Hill SA. Microwave disinfection of
dentures for the treatment of oral candidiasis. Spec Care
Dentist J 2001; 21:4–8.
9. American Dental Association Specification
No.12.Guide to dental materials and devices. 10th ed.
Chicago;1999. p.32.
10. Rizgar MA. The effect of addition of radiopaque
materials on some mechanical and physical properties
of flexible denture base[Ph.D. thesis]. Department of
Prosthetic Dentistry, Hawler Medical University; 2009.
11. Consani RLX, Azevedo DD, Mesquita MF, Mendes
WB, Saquy PC. Effect of repeated disinfections by
microwave energy on the physical and mechanical
properties of denture base acrylic resins. Braz Dent J
2009; 20: 132-7.
12. Mohammed FN. The effect of flasking tension system
on the adaptation of acrylic resin denture base in
different palatal models and base thicknesses [Master’s
Thesis]. Department of prosthetic Dentistry, University
of Baghdad; 2007.
13. Harper CA. Handbook of plastics, elastomers and
composites. 4th ed. The McGraw-Hill Companies; 2004.
p.23-25.
10
J Bagh College Dentistry Vol. 23(3), 2011 Cuspal deflection in premolar

Cuspal deflection in premolar teeth restored with a

Silorane and a Dimethacrylate-resin based composite
(A comparative study)
Ayad M. Mahmoud Al-Obaidi B.D.S. (1)
Inas I. Al-Rawi B.D.S. M.Sc. (2)

ABSTRACT
Background: This study was conducted to evaluate and compare the cuspal deflection between 2 low-shrinkage
resin composites ( Filtek™ Silorane ) and ( Tetric EvoCeram ), and the effect of using light-cured GIC (Vivaglass® Liner)
and storage in water on cuspal deflection at different periods.
Materials and methods: Forty extracted maxillary first premolars of approximately similar sizes were prepared with
standardized MOD cavities. The sample teeth then divided into two main groups ( 20 specimens each ) according to
the restorative material ( group A Filtek™ Silorane and group B Tetric B1: restored by Tetric EvoCeram with Vivaglass®
Liner. Group B2: restored only by Tetric EvoCeram. All samples restored with oblique incremental technique. The
intercuspal distance was measured before and after the restorative procedures and after 1, 2 and 4 weeks of water
storage and the difference were recorded as cuspal deflection. Cuspal deflection was measured using digital
micrometer. Data were analyzed statistically by ANOVA and least significant difference (LSD) test.
Results: Filtek™ Silorane significantly less cuspal deflection. Vivaglass® Liner significantly reduced cuspal deflection
with Tetric EvoCeram. After four weeks water storage, cuspal deflection in all subgroups were highly significantly
different with the two restoratives (P<0.01) . While light-cured glass ionomer cement has a non significant effect on
cuspal deflection after 4 weeks.
Conclusions: Silorane showed lower cuspal deflection and lower water uptake than Tertic EvoCeram. Polymerization
shrinkage deformation was almost compensated by hygroscopic expansion within 4 weeks.
Key words: Cuspal deflection, Silorane, Tetric Evoceram, hygroscopic expansion. (J Bagh Coll Dentistry 2011;23(3):
11-16).

INTRODUCTION Post-operative sensitivity by fluid flow in

Interest in aesthetic dentistry has resulted in
tooth colored restorations being increasingly used,
not only as a replacement material for failed or
unaesthetic amalgam, but as the first choice
material to restore previously ‘virgin’ posterior
teeth (1).
Polymerization shrinkage that occurs during
light-curing of resin-based restorative materials
inside a cavity may result in cuspal deflection,
enamel crack propagation or debonding of the
restoration (2).
Tooth deformation is indicative of a
combination of stresses in the tooth, in the
restoration or across the tooth-restoration
interface. The size and configuration (C-factor) of
the cavity influence the amount of cuspal
deflection and the highest deflection values have
been recorded for mesio-occluso-distal (MOD)
cavities (3) .
(1) Assistant lecturer, Conservative Department, College of
Dentistry, University of Baghdad.
(2) Professor, Conservative Department, College of dentistry,
University of Baghdad.
exposed dentinal tubules has been associated with
cuspal deflection due to the formation and/or
propagation of enamel cracks or by gap formation
at the interface between the tooth and the resin
based composite restoration as a result of bending
and/or insufficient bond strength. Cuspal
deflection may compromise the synergism of the
bond at the tooth restoration interface possibly
leading to bacterial microleakage and ultimately
to marginal discoloration, secondary caries and
pulpal inflammation or necrosis (3).
Filtek™ Silorane low shrink resin based
composites have been introduced, it is based on
new Silorane chemistry comprised of ring-
opening monomers that provide for low
polymerization shrinkage aiming at reducing the
polymerization shrinkage, therefore cuspal
deflection and stress at the tooth–restoration
interface will be reduced. Studies reported a
decrease in total cusp deflection in MOD cavities
restored with low shrink Silorane resin based
composites. In addition incremental placement of
composites is recommended by most
manufacturers to maximize curing, to minimize
polymerization shrinkage and to reduce gap
formation and cusp deflection (4) .
Dimensional changes, both shrinkage and
expansion, of a restorative material have a major
impact on the clinical success of a restored tooth

Restorative Dentistry 11
J Bagh College Dentistry Vol. 23(3), 2011
in a humid oral environment, polymerization
shrinkage may be alleviated by hygroscopic
expansion from water absorption (5) .
MATERIALS AND METHODS
Teeth selection
Forty sound first premolar teeth extracted for
orthodontic purposes, collected from different
health centers in Baghdad. The teeth had been
stored in distilled water at room temperature until
use (3). To minimize variables all teeth that were
used in the investigation had regular occlusal
anatomy and approximately similar crown size,
sound and free from hypopalstic defects and
cracks on visual examination and using light cure
(7, 8)
. Any calculus deposits were carefully
removed with Air scaler (Victor C9000) and teeth
were polished with pumice (Alpha pro) (3). • Group B1: Ten teeth restored by Tetric-
Each tooth was mounted vertically using a
Cold cure acrylic powder and liquid, type 1 class
(Dentsply) in a square plastic mould with
dimensions of 23 x 12mm x 12mm. The resin • Group B2: Ten teeth restored by Tetric-
should be extended to within 2 mm of the
amelocemental junction (ACJ) (5,8) .
A 1.5 mm diameter glass ball was fixed to
each cusp as reference points for intercuspal
distance measurements using Adhesive
techniques, using acid etch Alpha-Etch37® (37%
phosphoric acid gel) (Lincolnwood, Illinois) for
30 seconds followed by application Tetric N bond
(vivadent/ivoclar) and cured 20 second and then
Tetric-N ceram (vivadent/ivoclar) light cure
composite cured 20 seconds (8,9) .
Cavity preparation
Each tooth was subjected to preparation of a
large mesio-occlusal-distal (MOD) cavity, with
the parallel walls (9) using a Diamond flat-ended
fissure bur (REF FG 108M010, Hahnenkratt) in a
high speed handpiece (W&H) with water coolant
(A new bur was used for every five preparations).
The cavosurface margins were prepared at 90°
and axiopulpal and axiogingival line angle were
rounded with small round bur.
The cavity depth at the occlusal isthmus was
standardized (3.0 mm) and all gingival walls were
located above the amelocemental junction (ACJ)
at the cervical aspect of the proximal boxes. The
width of the floor and the width of the gingival
floor were 3 mm; the axial gingival depth and
axial height were 1mm for each. The cavity depth
and width were checked by a graduated
periodontal probe.
Sample distribution
The experimental teeth were divided into
two groups; twenty teeth each, according to the
restorative material and each group is subdivided
Restorative Dentistry
Cuspal deflection in premolar
into two subgroups ten teeth each according to the
restorative technique:
Group A: Twenty teeth where restored by
Silorane low shrinkage dental composite shade
A3 (3M ESPE) in (MOD) cavities. This group
subdivided according to the restorative technique
into:
• Group A1: Ten teeth restored by Silorane (3M
ESPE) in (MOD) cavities with placement of
Vivaglass liner (vivadent/ivoclar).
• Group A2: Ten teeth restored by Silorane (3M
ESPE) in (MOD) cavities without placement of
Vivaglass liner (vivadent/ivoclar).
Group B: Twenty teeth where restored by low-
shrinkage Tetric EvoCeram (vivadent/ivoclar) in
(MOD) cavities. This group subdivided according
to the restorative technique into:
EvoCeram (vivadent/ivoclar) in (MOD) cavities
with placement of Vivaglass liner
(vivadent/ivoclar).
EvoCeram (vivadent/ivoclar) in (MOD) cavities
without placement of Vivaglass liner
(vivadent/ivoclar) .
Tooth restoration
Four different restorative techniques were
used in the investigation:
Group A1: After complete cavity preparation , a
light-cured glass ionomer cement Vivaglass liner
(vivadent/ivoclar) was applied on the pulpal floor
and axial walls according to manufacturer’s
instruction, the cavity cleaned and dried in the
customary manner. The standard powder/liquid
ratio of 1.4 g/1.0 g can be achieved with a level
Vivaglass measuring spoon of powder and one
drop of liquid. The required amount of powder
and liquid dispensed onto the mixing pad, the
powder divided into two equal parts, the first half
mixed with the liquid for approx. 5–10 seconds,
the second half of the powder added for another
5–10 seconds. Total mixing time should not
exceed 20 seconds, then the Vivaglass Liner
adapted into axial and pulpal floor in a thickness
of about 0.5 mm, then the material cured for 30
seconds with a Light cure device, after that
Silorane System Adhesive (3M ESPE) was
applied according to the manufacturer’s
instruction, the Silorane System Adhesive primer
placed to the entire cavity for 15 seconds then
dispersed with a stream of air and light-cured the
primer for 10 seconds then Silorane System
Adhesive bond (3M ESPE) rubbed and light-
cured for 10 seconds. Silorane composite shade
A3 (3M ESPE) was placed into the cavity using
CompoRoller™ ( KERR ) instrument which is an
innovative composite modelling instrument that is
12
J Bagh College Dentistry Vol. 23(3), 2011
designed to provide complete control in layering
and contouring of direct composite restoration to
its final form. The composite resin was placed in
wedge-shaped incremental insertion technique.
The first increment was placed against the palatal
wall and gingival seat of the proximal boxes and
polymerized. Then, composite resin was placed
against the facial wall and polymerized. This
procedure was repeated for the occlusal portion of
the preparation and the number of total increment
was 4 increments for each tooth. The restoration
was progressively built up with increment not
exceed 2 mm. Each increment was light-cured for
40 seconds using a visible-Light cure device
(Type: Halogen light), (Light intensity:
400mW/cm2) (Dentsply) only from the occlusal
surface (10) .
Group A2: Silorane System Adhesive and low
shrinkage Silorane (3M ESPE) was applied as in
subgroup A1.
Group B1: Light-cured glass ionomer cement
Vivaglass liner (vivadent/ivoclar) was applied on
as in subgroup A1, then AdheSE self etching
adhesive (vivadent/ivoclar) was applied, first
AdheSE Primer (vivadent/ivoclar) was applied for
30 seconds, primer dispersed with stream of air,
and AdheSE Bond (vivadent/ivoclar) rubbed in
and light-cured for 10 seconds.
Tertic Evoceram (vivadent/ivoclar) was
placed into the cavity as in group A (10) .
Group B2: AdheSE self etching adhesive and
low shrinkage Tertic Evoceram (vivadent/ivoclar)
composite was applied as in group B1.
In all cases, the matrix band was placed
without using a retainer in order to avoid any
tension on the cusps (7) .
Sample measurement
All measurements were performed by the
same operator and ten consecutive measurements
were recorded for each sample and the mean was
used for the subsequent statistical analysis (8) .
The intercuspal distance of unaltered tooth
(ID) was measured before any restorative
procedures. The intercuspal distance between
reference balls was measured with a digital
micrometer (CT Brand, 200-521, Wah Luen
electronics).The mean values of the ten
consecutive measurements of intercuspal distance
after cavity preparation for each tooth recorded as
‘initial distance’.
The samples were stored in distilled water in
plastic tube 15 minutes after the polymerization of
the last increment of composite, the distance
between the glass balls (intercuspal distance 15
min. after tooth restoration) measured and the
mean value of the ten consecutive measurements
for each tooth recorded as ‘final distance’. The
Restorative Dentistry
Cuspal deflection in premolar
cuspal deflection (CD2) was obtained by
calculating the difference between ‘final’ and
‘initial’ measurements (9) .
After that the teeth were stored in deionized
distilled water (Al-Mansur factory) in plastic
tubes and placed in the Incubator (Binder) in 37°C
in Al-Yarmouk Teaching Hospital for one , two
and four weeks, cuspal deflection were measured
after each period .
The effect of water storage on cuspal
deflection following placement of MOD
composite restorations after one, two and four
weeks of water storage measured by subtracting
the intercuspal distance after water storage in
different periods from intercusapl distance 15
min. after tooth restoration (Final distance).
RESULTS
1. Shrinkage pulls cusps together, recording
negative cuspal deflection values on the buccal
and palatal surfaces. Cuspal deflection 15 min.
after tooth restoration the statistical analysis of
data by one - way ANOVA showed a highly
significant difference (P < 0.01) between the two
restoratives as shown in Table 1. Further analysis
of all data is needed to examine the difference
between subgroups and explore the effect of
Vivaglass liner on the cuspal deflection, so least
significant difference (LSD) of cuspal deflection
15 min. after tooth restoration shown in Table 3.
The cuspal deflection 15 min. after tooth
restoration showed highly significant difference
(P<0.01) between all subgroups except between
subgroup (A1&A2) there is a non significant
difference (P>0.05).
2. Expansion pushed the buccal and palatal
surfaces outwards, resulting in positive
deformation values. the Positive Cuspal
Deflection (CD3) which represent hygroscopic
expansion in Silorane group A has lower mean
value (+ 5.3350 and + 5.6360) compared with
Tetric EvoCeram group B ( + 9.7290 and +
9.7700) and the difference is highly significant
Table2. The same behavior of the shrinkage
deformation reduction continued after two weeks
water storage and the hygroscopic expansion
(Positive Cuspal Deflection) (CD4) between the
two restoratives was a highly significant
difference. The gradual reduction continued after
four weeks water storage, but in much less degree
than at one and two weeks water storage, the
hygroscopic expansion (Positive Cuspal
Deflection) after four weeks water storage (CD5)
between the two restoratives was statistically
highly significant difference as shown in Table 2.
In regard to the effect of light-curing glass
ionomer on the cuspal deflection after water
13
J Bagh College Dentistry Vol. 23(3), 2011 Cuspal deflection in premolar

storage periods, the total amount of hygroscopic Table 3: LSD test at different periods of
expansion (Positive cuspal deflection) after four restorative procedures for all sub groups.
weeks water storage Table 3 for (A1 &B1) was ANOVA
slightly higher than that in the cavity restored with Sub- test
Silorane or Tetric EvoCeram only (A2&B2) Variable Mean ±SD
group F- p-
statically there is a non significant difference in test value
all water storage periods as shown in Table 3. Positive CD A1 5.636 1.3375
3. The percentage of natural tooth dimensional after 1W A2 5.335 1.2595
recovery after four weeks water storage showed 26.82 0.000
water B1 9.729 0.2201
that according to the data presented in the results, storage B2 9.77 2.3741
following hygroscopic expansion, was 99.99277 Positive CD A1 7.423 2.3582
% for subgroup A1 restored with Silorane with after 2W A2 7.032 1.9312
RMGIC liner, 99.98792 % for Silorane subgroup 9.388 0.000
water B1 13.06 4.3096
A2, 99.99845 % for subgroup B1 restored with storage B2 13.19 4.6462
Tetric EvoCeram with RMGIC liner and 99.98845 Positive CD A1 7.969 2.363
% for subgroup B2. after 4W A2 7.681 2.1543
5.789 0.002
water B1 13.48 8.1131
Table 1: Mean, standard deviation and storage B2 14.1 2.565
ANOVA test of negative cuspal deflection 15
min. (CD2) after tooth restoration mean
values for all sub groups.
DISCUSSION
Cuspal deflection regarded as a topic of
ANOVA test
interest as it indicates residual (internal) stresses
(d.f.=39)
Subgroups Mean ±SD in the tooth structure that may cause failure during
F- p-
composite curing or act as a preloading,
test value
facilitating tooth fracture under occlusal loads. (1,8,
A1 -4.1603 0.72026 13)
.
A2 -4.9773 1.36569 0.000
81.915 Large MOD cavities were prepared in the
B1 -9.087 1.33061 HS
present study because its favors potential cuspal
B2 -10.8337 0.93796
deflection, the larger the cavity size, the greater
was the cusp deflection. Two points can explain
Table 2: Mean, standard deviation and this: First, there was less tooth structure left in
ANOVA test of positive cuspal deflection large cavities, which meant more flexibility of the
(CD3),(CD4), (CD5) after water storage cusps and more compliance with composite
mean values for all sub groups. shrinkage. As the cavity preparation becomes
p- wider and deeper, the strength of the prepared
Variable Sub-group MD SIG
value tooth is considerably reduced and the tooth
A1 & A2 -0.817 0.112 NS becomes more flexible. Second, the greater total
CD 15 min.
A1 & B1 -4.9267 0.000 HS volume of composite needed for restoration of
after tooth
A2 & B2 -5.8564 0.000 HS large cavities results in a higher shrinkage force
restoration (7,14,15,16)
B1 & B2 -1.7467 0.001 HS .
A1 & A2 0.301 0.657 NS In this study, the matrix band was placed
Positive CD
A1 & B1 -4.093 0.000 HS without using a retainer in order to avoid any
after 1W
A2 & B2 -4.435 0.000 HS tension on the cusps also its placement may
water storage
B1 & B2 -0.041 0.952 NS interfere with the presence glass balls in the
A1 & A2 0.3914 0.805 NS samples (7) .
Positive CD
A1 & B1 -5.6336 0.001 HS Oblique incremental technique was used in
after 2W
A2& B2 -6.15336 0.000 HS order to avoid or delay the bonding of opposing
water storage
B1& B2 -0.12836 0.935 NS cusps together, thus reducing the stress within the
A1 & A2 0.2884 0.888 NS restoration. Wedge-shaped composite increments
Positive CD
A1 & B1 -5.5176 0.01 HS are placed to prevent distortion of cavity walls
after 4W
A2& B2 -6.4227 0.003 HS and reduce the C-factor. The oblique incremental
water storage
B1& B2 -0.6167 0.763 NS technique of resin composite has been proposed to
reduce the composite mass to be polymerized and
the resulting shrinkage stress. Restoring large
cavities in several increments has been shown to
distribute the contraction strain among the

Restorative Dentistry 14
J Bagh College Dentistry Vol. 23(3), 2011
increments, reduce the stress on the cusps, and
result in less cusp deflection (7,14,17 , 18) .
Intercuspal distances were measured 15 min
after polymerization, because the majority of
cuspal deflection is reported to occur within this
period and the teeth were fully hydrated (7, 14).
All experimental subgroups showed a
reduction in intercuspal distance after the
restorative procedure. The Polymerization
shrinkage of composite restorations resulted in an
inward deflection of the cusps for all the
experimental subgroups evaluated ( 5,8,9,13-16,18) .
The Silorane-based resin composite caused
less cuspal deflection compared to the
Dimethacrylate–based resin composite
(3,12,13,15,19,20,21)
.The statistical analysis of data
showed a highly significant difference between
Silorane Group A and Tetric EvoCeram Group B
of means value Table 1, the main explanation is
based on the different polymerization process of
the two low shrinkage composites, Silorane based
on a new chemical composition for the matrix
system. The Silorane monomer was developed
with a primary target of overcoming some
drawbacks pertaining to the polymerization of
dimethacrylate -based resin composites, like
radical oxygen inhibition, polymerization
shrinkage, polymerization stress, and water
sorption, the cationic ring-opening polymerization
process of the Silorane-based composite due to
the presence of oxirane species yielding a reduced
volumetric shrinkage in comparison to the free-
radical addition reaction of the double bonds of
the dimethacrylate-based composite. Siloranes
have a polymerization reaction with a slow onset
as the cation formation needs more time than a
free radical formation mechanism, allowing time
for flow of material and stress relaxation,
resulting in less cuspal deflection (13,22,23) .
Regarding to the effect of Vivaglass liner, in
group A Silorane, the negative cuspal deflection
mean value for subgroup A1 was (- 4.1603) and
has lower mean value than subgroup A2 (-
4.9773), but the difference is not statically
significant Table 3, there is no study to compare
with it and that might due to the low shrinkage
behavior of Silorane. In Group B Tetric-
EvoCeram there is a highly significant difference
between (B1&B2) Table 3 because the use of
Vivaglass base material, there is less volume of
composite needed for restoration that results in a
less shrinkage force, the polymerization shrinkage
stress of RMGIC is much lower than that of the
composites, and the RMGIC under the composites
reduced the level of polymerization shrinkage of
the composites, this showed by Alomari et al 17
reported that cuspal deflection was also lower in
Restorative Dentistry
Cuspal deflection in premolar
the MOD cavity when RMGIC was used as a base
material than that cavities restored with the
composite resin only. Castaneda-Espinosa et al 21
and Kwon et al 22 found that RMGIC intermediate
layer promoted significant decrease in
polymerization contraction force values of the
restorative system. While Taha et al 4 concluded
that the placement of glass ionomer did not
significantly reduce the amount of cusp
deflection, but its placement is beneficial in
reducing strain and marginal leakage.
The gradual increase in positive cuspal
deflection behaviors could be relate to bond
failure between restoration and tooth could have
relaxed the cuspal deflection. Bond failure is
unlikely to be consistent across different samples
because it is expected to be strongly dependent on
individual samples and preparation conditions.
Stress relaxation of the resin composite could also
reduce cuspal flexure. It is known that a
composite restoration exhibits some stress
relaxation due to water absorption. Stress
relaxation can be caused by the viscoelastic
properties of composites, while water absorption
may increase relaxation through hydrolysis
(chemical degradation of the polymers) and
plasticization (water induced molecular mobility)
effects (6) .
The Silorane-based composite showed less
water uptake (hygroscopic expansion) than
dimethacrylate-based composite this is due to the
Silorane-based composite revealed increased
hydrophobicity due to the presence of the siloxane
species in its composition this decreased water
sorption, solubility and associated diffusion
coefficient compared with dimethacrylate resin
based composites, also the nano-composites
seemed to be more degraded by longer storage in
water than the microhybrids (6,23,26,27) .
In regard to the effect of light-curing glass
ionomer on the cuspal deflection after water
storage periods , the total amount of hygroscopic
expansion ( Positive cuspal deflection ) after four
weeks water storage Table 3 for (A1 &B1) was
slightly higher than that in the cavity restored with
Silorane or Tetric EvoCeram only (A2&B2) , this
occurred because the HEMA present in the liquid
of the RMGIC is hydrophilic in nature, and
materials with a higher HEMA content have
consequently higher water sorption and
statistically there is a non significant difference in
all water storage periods as shown in Table 3 ,
other studies Yap 25 Mortier et al 26 showed that
the RMGIC absorbed more water than the resin
composite, there results were significant, the
difference could be due to different composites
materials and to different sample size .
15
J Bagh College Dentistry Vol. 23(3), 2011
Under the experimental conditions in this
study the initial shrinkage deformation was
returned almost completely to the natural tooth
dimension after 4 weeks water storage, the results
comparable with Versluis et al 5, while Segura and
Donly 27 reported that more than 97% of the
cuspal deflection caused by polymerization
shrinkage of a resin composite restoration was
reported to have recovered after 6 months
immersion in water. Thus the amount of
hygroscopic expansion and its clinical impact may
vary with material characteristics.
REFERENCES
1. Fleming GJ, Hall DP, Shortall AC, Burke FJ.
Cuspal movement and microleakage in premolar
teeth restored with posterior filling materials of
varying reported volumetric shrinkage values. J Dent
2005; 33(2):139-46.
2. Gamba J, Forchelet J, Cattani-Lorente M,
Chatelain V, Krejci I, Bouillaguet S, Yverdon-les-
bains. Cuspal deformation during light-curing of
resin-based restorative materials measured by ESPI
(Electronic Speckle Pattern Interferometry).
European Cells and Materials 2004; 7(2):32-3.
3. Cara RR, Fleming GJ, Palin WM, Walmsley
AD, Burke FJ. Cuspal deflection and microleakage in
premolar teeth restored with resin-based composites
with and without an intermediary flowable layer. J
Dent 2007; 35(6):482-9.
4. Taha NA, Palamara JE, Messer HH. Cuspal
deflection, strain and microleakage of endodontically
treated premolar teeth restored with direct resin
composites. J Dent 2009; 37(9):724-30.
5. Versluis A, Tantbirojn D, Lee MS, Tu LS,
Delong R. Can hygroscopic expansion compensate
polymerization shrinkage ? Part I. Deformation of
restored teeth. Dent Mater 2011; 27(2):126-33.
6. Pascal M. , Tevan O. CT scan –based finite
element analysis of premolar cuspal deflection
following operative procedures. Int J Periodontics
Restorative Dent 2009; 29(4):361-9.
7. Gonzalez-Lopez S, Sanz Chinesta MV, Ceballos
García L, de Haro Gasquet F, González Rodríguez
MP. Influence of cavity type and size of composite
restorations on cuspal flexure. Med Oral Patol Oral
Cir Bucal 2006; 11(6):E536-40.
8. Campos EA, Andrade MF, Porto-Neto ST,
Campos LA, Saad JR, Deliberador TM, Oliveira-
Júnior OB. Cuspal movement related to different
bonding techniques using etch-and-rinse and self-etch
adhesive systems. Eur J Dent 2009; 3(3):213-8.
9. Santos MJ, Bezerra RB. Fracture resistance of
maxillary premolars restored with direct and indirect
adhesive techniques. J Can Dent Assoc 2005; 71
8:585.
10. Cara Ilici RR , Eduard G ,Elena M , Andreea D,
Codruta N , Ion P. Cuspal deflection and adhesive
interface integrity of low shrinking posterior
composite restorations. Acta Stomatologica Croatica
2010.
Restorative Dentistry
Cuspal deflection in premolar
11. Suliman AA, Boyer DB, Lakes RS. Cusp
movement in premolars resulting from composite
polymerization shrinkage. Dent Mater 1993; 9:6-10.
12. Palin WM, Fleming GJ, Nathwani H, Burke FJ,
Randall RC. In vitro cuspal deflection and
microleakage of maxillary premolars restored with
novel low-shrink dental composites. Dent Mater
2005; 21(4):324-35.
13. Abbas G, Fleming GJ, Harrington E, Shortall
ACC, Burke FJT. Cuspal movement and
microleakage in premolar teeth restored with a
packable composite cured in bulk or increments. J
Dent 2003; 31:437-44.
14. Yamazaki PC, Bedran-Russo AK, Pereira PN,
Wsift EJ. Microleakage evaluation of a new low-
shrinkage composite restorative material. Oper Dent
2006; 31(6):670-6.
15. Versluis A, Douglas WH, Cross M, Sakaguchi
RL. Does an incremental filling technique reduce
polymerization shrinkage stresses. J Dent Res 1996;
75(3):871-8.
16. Park J, Chang J, Ferracane J, Lee IB. How
should composite be layered to reduce shrinkage
stress: Incremental or bulk filling. Dent Mater 2008;
24(11):1501-5.
17. Alomari QD, Reinhardt JW, Boyer DB. Effect of
liners on cusp deflection and gap formation in
composite restorations. Oper Dent 2001; 26: 406- 11.
18. Bouillaguet S, Gamba J, Forchelet J, Krejci I,
Wataha JC. Dynamics of composite polymerization
mediates the development of cuspal strain. Dent
Mater 2006; 22(10):896-902.
19. Ilie N, Hickel R. Silorane-based dental
composite: behavior and abilities. Dent Mater 2006;
25(3):445-54.
20. Shawkat ES, Shortall AC, Addison O, Palin
WM. Oxygen inhibition and incremental layer bond
strengths of resin composites. Dent Mater 2009;
25(11):1338-46.
21. Castaneda-Espinosa JC, Pereira RA, Cavalcanti
AP, Mondelli RF. Transmission of composite
polymerization contraction force through a flowable
composite and a resin-modified glass ionomer
cement. J Appl Oral Sci 2007; 15(6): 495-500.
22. Kwon OH, Kim DH, Park SH. The influence of
elastic modulus of base material on the marginal
adaptation of direct composite restoration. Oper Dent
2010; 35(4):441-7.
23. Ilie N, Hickel R. Macro, micro and nano-
mechanical investigations onsilorane and
methacrylate-based composites. Dent Mater 2009;
25(6):810-9.
24. Al-Boni R, Raja OM. Microleakage evaluation
of silorane based composite versus methacrylate
based composite. J Conserv Dent 2010; 13(3):152-5.
25. Yap AUJ. Resin-modified glass ionomer
cements: a comparison of water sorption
characteristics. Biomaterials 1996; 17(19):1897-900.
26. Mortier E, Gerdolle DA, Jacquot B, Panighi
MM. Importance of water sorption and solubility
studies for couple bonding agent – resin-based filling
material. Oper Dent 2004; 29(6):669-76.
27. Segura A, Donly KJ. In vitro posterior
composite polymerization recovery following
hygroscopic expansion. J Oral Rehabil 1993;
20(5):495-9.
16
J Bagh College Dentistry Vol. 23(3), 2011 Influence of dental cleansers

Influence of dental cleansers on the color stability and

surface roughness of three types of denture bases
Hussam M Saied B.D.S, M.Sc. (1)

ABSTRACT
Background: This study is concerned with color stability and surface roughness of three types of denture base
materials when immersed into three types of denture cleansers.
Materials & method: Forty five specimens were prepared, fifteen of each type were immersed into distilled water for
48hours which regarded as control and then each five specimens were immersed into one of three different denture
cleansers for twelve hours then undergone testing for color stability and surface roughness ,the results were analyzed
by paired t-test and ANOVA test.
Results: In color stability the hot cure acrylic give non significant difference p>0.05 with denture cleansers, the soft
base give (HS) high significant difference which is greatly affected by denture cleansers while the nylon denture was
significantly affected by bleach rather than the other two cleansers was non significant. The ANOVA test show
smooth effect of fitty dent (NS)on both nylon and soft base. The surface roughness test it was significantly affected by
denture cleansers by t-test while ANOVA the smooth effect of both fitty and lacalut dent on denture bases with non
significant difference.
Conclusion: Denture cleansers can cause whitening or color fainting or even bleaching. The surface texture affected
by cleansers in deferent level according to time of immersion, concentration and type of active component that
lead to increase of roughness or wear of denture outer surface. The effect of fitty dent was safer in its action and
smoother than bleach and lacalut.
Key words: Denture base, dental cleaners, surface roughness. (J Bagh Coll Dentistry 2011;23(3): 17-22).

INTRODUCTION
Almost all complete dentures are fabricated
by using an acrylic resin, low cost material that
requires relatively ease manipulation and
construction methods. How ever its not the ideal
material in every aspects.
Discoloration of acrylic resin results in
esthetic problems and the denture base polymers
should have a good esthetic and smooth glassy
surface and should be capable of matching the
natural appearance of the soft tissue (1)
Color and translucency should be maintained
during processing and the resin should not be
stained or change color during clinical use. Color
stability is an important factor for many dental
materials. (2) These dentures should be accurate
and fit inside patient mouth which is an important
rule. (3)
How ever the process of alveolar resorption is
irreversible and may lead to in adequate fit of the
prosthesis (4) , the use of resilient lining materials
is useful in removable prosthdontics because of
their capability of restoring health to inflame ed
mucosa (5,6), leading to more equal distribution of
functional load on the denture functional area (7,8)
(1) Assistant lecturer/prosthodotic department collage
dentistry/Baghdad University
In recent years ,nylon polymer has been
attracting attention as a denture base material
because of multiple advantages like favorable
esthetic outcome, toxological safety to patient
allergic to conventional metals and resin
monomers (9,10), higher elasticity than
conventional heat polymerized resins and
sufficient strength for use as a denture base
material (11)
As well as the use of heat modeling instead of
chemical polymerization to ease conventional
challenges such as deformation during the
polymerization process and the presence of non
polymerized residual monomer (12,13)
Due to exposure of these denture bases to
different food and drink colorants that lead to
denture staining, these color changes give the
demand for the denture cleansers which are
commercially available with different types (14,15)
Denture cleansers remove the outer staining
and widely used to prevent plaque formation and
bacterial colonization (14)
However, denture cleansers can cause
significant deterioration because they can cause
loss of soluble components and plasticizers and/or
absorption of water and other salivary component
by the resilient denture base material that lead to
more surface roughness and color change (17,18)
The purpose of this study is to determine the
influence of denture cleansers on the color
stability of three different types of denture base
of materials.

Restorative Dentistry 17
J Bagh College Dentistry Vol. 23(3), 2011
MATERIAL AND METHODS
Three types of denture base materials were
chosen to be tested in this study which are mostly
used now a days for denture construction which
are hard hot cure acrylic (Major Dent, Italy), hot
cure soft base silicon (Vertex, Nethrlands) and
Nylon or flexite supreme denture base rapid
injection system (Menniola NY) (19). These are
selected to evaluate the effect of deferent denture
cleansers o n color stability and surface roughness
of denture bases made from them.
The denture cleansers that has been used in
this study were three types with different
ingredients one of them was commercially
available and (Bleach), while the two other types
supplied as tablets give their effect when socked
into water (denture cleansing tablets) as shown in
the table 1.
Fifteen specimens for each material were
constructed as a disc of 50mm in diameter &
1mm thickness according to ADA specification
(20)
. prosthodontics.
These are firstly constructed by using flexible
nylon sheet that was prepared for inter occlusal
appliance for teeth whitening by biostar which
had thickness of 1mm,these were cut as discs of
50mm diameter ,then poured into metal flask one
disc for each flask ,when stone was completely set
,the flexible disc was removed by sharp clamp ,
then after that separating media was applied.
Both the hard and soft base acrylic were
packed and processed according to manufacture
procedure manual.
While the nylon was under gone heating and
injection by special thermal press device to
construct the final discs .These specimens were
smoothed and polished by Lathe cut polishing
machine. all specimens were washed and kept into
distilled water for 48 hours at 37C for several
days and then under gone testing.
Evaluation of surface roughness
A five specimens were selected randomly to be
undergone the surface roughness test as a control
Restorative Dentistry
Influence of dental cleansers
before the cleansers application. The surface
roughness test was done by measuring the average
surface roughness (Ra) using Analyzing surface
roughness tester (TR220 portable roughness
tester, Beijing, Time high technology. Ltd, China)
device. According to managing protocol the tester
take a distance 8mm on the surface of the tested
material which crossed by sensible needle ,this
area of examination was selected and marked by
the operator which should be smooth and
encircled in away to check the same area before
and after cleansers application (21,22)
Color evaluation
Color measurements were done for each specimen
by using an ultra violet –visible light recording
spectrophotometer model UV-160A,
Shimadzu,Kyoto,Japan) wave length 200-900nm
(23,24)
Denture cleansers application
Five specimens of each material were immersed
in each denture cleansers for 12 hours at 25° C,
washed thoroughly with tab water and then
immersed in distilled water for 12 hours at 37°C ,
then applied these specimens were subjected for
color change measurements (25)
RESULTS AND DISCUSSION
The null hypothesis that there would be no effect
of denture cleansers on the color stability of
denture base acrylic resin was rejected. However
the influence of denture cleansers on the color
stability of denture base material was different
according to difference in the types of these bases
& cleansers active components Longevity of
denture base materials is significant problem in
The color stability of a prosthesis may be the
most important factor for determining the patient
acceptance (26-28)
The color changes of all acrylic resins
increases as immersion time increases ,it has been
reported that denture cleansers can cause
whitening or color fainting or even bleaching,
loss of soluble components, water absorption in
acrylic resin materials this is in agreement with
Sarac D 2007 and Purnaveja S 1982 (28,29)
The mean values obtained were different
from each other according to difference in
denture base materials, the higher the value ,the
more is the consistency of the material with less
translucency of it, so it will absorb more light
before it can pass through it .
For the hot cure acrylic when immersed into
denture cleansers ,the mean value was not greatly
affected which documented by t-test that there
was (NS) no significant difference p˃ 0.05 with
control group and this was explained by the great
18
J Bagh College Dentistry Vol. 23(3), 2011
resistance of the resin material due to high cross
linking between the poly methyl meth acrylate .
The soft base liner is more affected by the
bleaching with (S) significant difference p˂ 0.05
with control & this occur due to effectiveness of
sodium hypochlorite by dissolving the organic
plasticizers ,while both Fitty & Lacalut dent give
(HS) highly significant difference p≤0.01 due to
the acidic ingredients of these cleanser which
were highly affecting of dissolving the
plasticizers. While the nylon flex is slightly
affected by the bleaching which give significant
difference in the test, otherwise both Fitty &
Lacalut dent although their acidic bases but they
give no effect on it, so (NS) no significant
difference were detected, the nylon flex is more
compact & its co polymer can be more resistance
to dissolve or react with acidic materials.
F-test describe the effect of the three
materials , the action of bleaching give highly
significant difference (HS) p≤0.01 due to great
difference in the chemical composition of them&
less cross linking between molecules .
The poly methyl methacrylate denture base
resin were hydrophilic that attract more water
soluble materials on the surface that absorption is
undoubtedly due primarily to the polar properties
of resin molecules. However, it has been proven
that the mechanism is diffusion of water
molecules that penetrate according to diffusion
law, but still the high bond due to cross linking
agent give its resistance (24)
In table (3) which describe the surface
roughness tests , from the mean values & t-test
that reveled there were a(S) p˂ 0.05 in the effect
of the whole cleansers in comparison with control
group .the hot cure acrylic had a dropping in the
mean values after immersing in cleansers which
mean that the surface will be smoother & this
explain why see a smear layer on the specimen
surface which had been undergone slight
dissolving of the surface particles ,longitudinally
this effect was not accepted because the material
wear by time which affect on the functional
properties of the denture, these observation come
in agreement with Nikawa et al. (14,15) who
observed that the high peroxide content and level
of oxygenation in the strongly alkaline solution is
a damaging factor for the denture base materials.
Some authors reported that some denture
cleansers can cause a loss of soluble components
or absorption of water or saliva by denture base
material (28,29)
Peroxide denture cleansers include an
effervescent component such as sodium perborate
or sodium bicarbonate, when these tablets
dissolve in water, sodium perborate decomposes
Restorative Dentistry
Influence of dental cleansers
to form an alkaline peroxide solution. This
peroxide solution subsequently release oxygen
and loosen debris by mechanical means (14,28)
Therefore use of these denture cleansers may
cause hydrolysis and decomposition of the
polymerized acrylic resin itself, this observation
may explain why these cleansers had a greater
influence on color stability of denture base.
The soft base liner with bleach had increase
in the mean values after bleaching with the
increase of roughness and this may be related to
dissolving of some large molecules & plasticizers
,although there was an increase in the surface
roughness but statistically has on benefit which
give (NS) .otherwise both fitty & lacalut dent by
t-test had (S) in which the effect of the materials
will drop the mean value make it with slight
smoother surface ,also the same effect found on
nylon flex in a (S) difference by the cleansers
action when compared with control group
immersed in distilled water.
ANOVA describe the effect of these cleansers
on different denture base materials, both bleach
and fitty dent had (HS) difference in their effect
on these denture bases, while the lacalut has mild
effect which give (S).
By the LSD test both bleach & fitty dent has
(HS) in their effect on the hot cure & soft base
liner while the lacalut give (S) .as well as the
same results of these cleansers when compared
the hot cure & nylon flex ,this may be explained
by the difference in the chemical composition &
physical properties between the denture base
materials. While for both soft base liner &nylon
flex has a(S) difference find by the effect of
bleach, but this was not find by the effect of both
fitty & lacalut dent which smoother effect on the
surface on the above denture base, so (NS) were
obtained
REFERENCES
1. Shotwell JL,Razzog ME, Koran A. Color stability of
long term soft denture liners. J Prosthet Dent 1992;
68: 836-8
2. Lee YK, Lim BS, Kim CW. Influence illumination
&view aperture size on color of dental resin
composite . Dent Mater 2004;20:116-23
3. Craig RG. Restore dental materials 10th ed. St Louis
;Mosby;1997 p528
4. Budtz-Jorgensen E. Prosthdontics for elderly
diagnosis & treatment. Chicago: Quintessence;
1999:42
5. Goll G, Smith DF, Plien JB. The effect of denture
cleansers on temporary soft lining. J Prosthet Dent
1983; 50: 466-72
6. Nikawa H, Iwanga H, Hamada I, Yuhta S. Effect of
denture cleansers on direct soft lining material. J
Prosthet Dent 1994;72:657-62
7. Aydin AK, Terziogin H, Akiny AE, Ulbyan K,
Hasierci N. Bond strength & failure analysis of
19
J Bagh College Dentistry Vol. 23(3), 2011 Influence of dental cleansers

lining materials to denture resin. Dent Mater
1999;15:24-8
8. Sinobad D, Murphy NM, Huggett R, Brook S. Bond
strength & rupture properties of some soft denture
liners. J Oral Rehabilitation 1992;19:151-60
9. Hargreaves AS. Nylon as a denture base material.
Dent pract,dent res 1971;22:122-128
10. Yunu SN, Rashid AA, Azmil L, Abu Hasan MI.
Some flexural properties of a nylon denture base
polymer . J Oral Rehabilitation 2005;32:65-71
11. Katumata Y, Hojo S, Ino S, Hamana N, Watanab T,
Suzuki y, Ikeya H, Morino T, Toyoda M.
Mechanical characterization of flexible nylon
denture base material .Bull Kenagawa Dent Col
2007;35:177-182
12. Degochi R, Polymide 6. Japan plastics 199-;41:35-
41
13. Hart H, Carien LE, Hart DJ. Tithe 10th ed ,Baifukan
Co ,Tokyo2006;pp:443-462
14. Nikawa H, Hamada T, Ymashiro T, Kumagai H. A
review of in vitro &in vivo methods to evaluate the
efficacy of denture cleansers 1999;12:153-159
15. Nikawa H, Iwang H, Hamada T, Yuhta S. Effect of
denture cleansers on direct soft denture lining
material.1994;72:657-62
16. Nikawa H, Hmada T, Ymamoto T. Effect of
salivary or serum pellicles on the candida albicanse
growth & bio film formation in soft lining materials
in vitro.J Oral Rehabil 1997;24:564-604
17. Braden M, Wrights PS. Water absorption & water
solubility of the soft lining material for acrylic
denture J Dent Res 1983;62:764-8
18. Joes DW, Hull GC, Sutow EJ, Langman MF,
Robertson KN. Chemical & molecular weight
analysis of prosthodontic soft polymers. J Dent Res
1991;70:874-9
19. Vedenbrink JP, Wolfaardt JF, Fullkner MG. A
comparison of various removable partial denture
clasp materials & fabrication procedure for placing
clasps on canine & premolar teeth. J Prosthet .Dent
1993;70:180-8
20. American national standard, American Dental
Association specification No12 April 23,1999
21. Evandro A Sartori, Caroline B Shmidt, Rosmary S
Arashinkai. Effect of microwave disinfection on
denture base adaptation & resin surface roughness.
Braz Dent J 2006;17(3):195-0
22. Ana Lucia Macado, Carlos E, Vergani, Lusiano
E.Perez. Hardness & surface roughness of eline and
denture base acrylic resin after repeated disinfection
procedure. J Prosthet Dent 2009; 102:115-122
23. Yu-Lin-Lai, Ho-Fu-Lui, Shyn-Yuan. In vitro color
stability stain resistance & water sorption of
removable gingival flange materials. J Prosthet Dent
2003;90:293-300
24. Nur Hersik, Senay Canany, Gulay Uzun. Faith
Yaldis . Color stability of denture base acrylic resins
in three food colorants. J Prosthet Dent 1999;
81:375-9
25. Guang Hory, Hiroshi Morata, Yiney AiLi, Taizo
Hamada. Influence of denture cleansers on color
stability of three types o denture base resin. J
Prosthet Dent 2009;101:295-313
26. Polyzois GL, Yanni Kakis SA, Zissis AJ. Color
change of denture base material after disinfection
and sterilization immersion. Int J Prosthod
1997;68:78-82
27. Anil N, Hekimoglu C, Sahin S. Color stability of
heat polymerized and auto polymerized soft denture
liners. J Prosthet Dent 1999;81:481-4
28. Sarac D, Sarac YS, Kurk M. The effectiveness of
denture cleansers on soft denture liners colored by
food colorants solution. J Prosthet Dent
2007;16:185-91
29. Puveja S, Fletcher AM, Ritchie GM, Amin WM.
Color stability of two self cure denture base
materials. Biomaterials 1982;3:249-50

Table 2: Mean and SD of Color stability tests before and after cleanser application
control bleach Fitty dent Lacalut dent
Mean 0.4592 0.4702 0.4616 0.3896
Hot cure acrylic
SD 0.0442 0.0713 0.041 0.072
Mean 2.058 1.541 1.347 1.317
Soft base lining
SD 0.014 0.1641 0.051 0.084
Mean 1.1404 0.931 1.239 1.052
Nylon flex
SD 0.168 0.076 0.168 0.077

t-test between before with Bleach, Fitty dent, Lacalut dent

bleach Fitty dent Lacalut dent
t-test P-value t-test P-value t-test P-value
0.806 0.950 0.123
Hot cure acrylic 0.262 0.066 1,952
NS NS NS
0.002 0.000 0.000
Soft base lining 7.639 26.573 21.871
S HS HS
0.013 0.458 0.189
Nylon flex 4.306 0.820 1.580
S NS NS
*P<0.05 Significant
**P>0.05 Non significant
***P<0.01 High significant

Restorative Dentistry 20
J Bagh College Dentistry Vol. 23(3), 2011 Influence of dental cleansers

ANOVA between groups

F-test P-value
P<0.01
Bleach 114.27
HS
P<0.01
Fitty dent 107.32
HS
P<0.01
Lacalut dent 187.44
HS
***P<0.01 High significant

LSD
bleach Fitty dent Lacalut dent
P-value P<0.01 P<0.01 P<0.01
Hot cure acrylic & Soft base lining
Sig HS HS HS
Hot cure acrylic & Nylon flex P-value P<0.01 0.01 P<0.01
Sig HS S HS
P-value 0.003 0.175 0.008
Soft base lining &Nylon flex
Sig S NS S
* P<0.05 Significant
**P<0.01 High

Table 3: Mean and SD of Surface roughness tests before and after cleansers
control bleach Fitty dent Lacalut dent
Mean 0.268 0.064 0.054 0.059
Hot cure acrylic
SD 0.161 0.034 0.012 0.012
Mean 0.735 0.916 0.322 0.501
Soft base lining
SD 0.197 0.136 0.065 0.231
Mean 0.723 0.402 0.332 0.443
Nylon flex
SD 0.199 0.039 0.054 0.127

t-test between before with after, Fitty dent, Lacalut dent

bleach Fitty dent Lacalut dent
t-test P-value t-test P-value t-test P-value
0.045 0.040 0.045
Hot cure acrylic 2.881 3.009 2.887
S S S
0.278 0.003 0.046
Soft base lining 1.254 6.476 2.851
NS S S
0.015 0.018 0.049
Nylon flex 4.096 3.890 2.183
S S S
*P<0.05 Significant
**P>0.05 Non significant

ANOVA between groups

F-test P-value
P<0.01
bleach 132.29
HS
P<0.01
Fitty dent 52.39
HS
0.002
Lacalut dent 12.52
S
*P<0.05 Significant
**P<0.01 High significant

Restorative Dentistry 21
J Bagh College Dentistry Vol. 23(3), 2011 Influence of dental cleansers

LSD
bleach Fitty dent Lacalut dent
P-value P<0.01 P<0.01 0.012
Hot cure acrylic & Soft base lining
Sig HS HS S
Hot cure acrylic & Nylon flex P-value P<0.01 P<0.01 0.003
Sig HS HS S
P-value 0.002 0.851 0.730
Soft base lining &Nylon flex
Sig S NS NS
*P<0.05 Significant
**P>0.05 Non significant

Restorative Dentistry 22
J Bagh College Dentistry Vol. 23(3), 2011 Evaluation the effect of modified

Evaluation the effect of modified nano-fillers addition on

some properties of heat cured acrylic denture base
material
Ihab NS, (1)
Moudhaffar M, (2)

ABSTRACT
Background: The poly(methylmethacrylate) (PMMA) shown to be lacking two properties which are strength and
radio-opacity. The aim of this study was to evaluate the effect of addition of modified nano-zirconium oxide (ZrO2)on
some properties of heat cured acrylic denture base material .
Material and method: (ZrO2) nanofillers were incorporated into (PMMA) denture base by free radical bulk
polymerization. (PMMA) nanoparticales were coated with a layer of trimethoxysilypropylmethacrylate (TMSPM)
before dispersed and sonicated in monomer (MMA) in different percentages 2%, 3%, 5% and 7% by weight. Then
mixed with acrylic powder as general conventional method. Two hundred fifty five (255) specimens were prepared
for this study they were divided into (6) groups according to the test used. The tests were impact strength,
indentation hardness, surface roughness, transverse strength, radio-opacity and microscope test, for each test five
subgroups (one control and four for nano-ZrO2). The size and shape distribution of nano-ZrO2 particles were
estimated using scanning electron microscope (SEM) and atomic force microscope (AFM) .
Result: Highly significant increase in impact and transverse strength occur in acrylic reinforced with 5wt%, but non
significant increase was observed at 7wt% when compared to control group. Non-significant increases in indentation
hardness and surface roughness appear with addition of modified nano-ZrO2 at different percentages. For radio-
opacity a highly significant increase had occurred with the addition of modified nano-ZrO2.
Conclusion: The maximum increase in impact strength, transverse strength and radio-opacity was observed in
denture base nano composite containing 5wt% of nano-ZrO2.
Key words: poly (methylmethacrylate), nano composite. (J Bagh Coll Dentistry 2011;23(3): 23-29).

INTRODUCTION
Poly (methylmethacrylate) (PMMA) is the
most commonly used material in construction of
denture base since 1930 . This material is not
ideal in every respect and it is the combination of
various rather than one single desirable of
properties that accounts for its popularity and
usage.Despite its popularity which satisfy
aesthetic, simple processing and easy repair, the
main problems associated with PMMA as denture
base material are poor strength particularly under
fatigue failure inside the mouth, impact failure
outside the mouth and lack of radio-opacity (1).
The PMMA used routinely today is radiolucent
and cannot be imaged using standard radiographic
techniques, so in cases of accidental ingestion,
aspiration and traumatic impaction of dental
appliance, their detection very difficult and
require invasive procedures as advanced imaging
techniques. Delay in localizing or removing the
foreign body may be life threatening (2). Recently,
much attention have been directed toward the
incorporation of in organic nanoparticles into
PMMA to improve its properties.
(1) Assistant Lecturer University of Baghdad, College of
dentistry, Prosthodontics department.
(2) Assistant Professor University of Baghdad, College of
dentistry, Prosthodontics department
The properties of polymer nanocomposites
depend on the type of incorporated nanoparticles,
their size and shape, as well as the concentration
and interaction with the polymer matrix (3).
Nanoparticles were undergone surface treatment
with saline coupling agent and embedded into
PMMA (4). Many attempts have been carried out
to incorporate inorganic nanoparticles into
PMMA. Alumina nanoparticles were coated with
acryloxypropyldimethyl methoxysilane to get
PMMA/alumina nanocomposite with increased
mechanical properties over pure PMMA(5).
Calcium carbonate nanoparticles modified with
stearic acid was incorporated into PMMA to
improve the abrasion resistance of PMMA(6).
Barium sulphate nanoparticles was added to
PMMA to enhance radiopacity (7) .This study was
conducted to use inorganic nanofillers that are
added to heat cure PMMA and test the effect of
this addition on radio-opacity and some
mechanical properties of heat cured acrylic
denture base material
MATERIALS AND METHOD
Surface modification of fillers (ZrO2, BaTiO3)
The introduction of reactive groups onto
fillers surface was achieved by reaction of 3-
trimethoxysilyl propylmethacrylate TMSPM
(meth acryloxy propyl trimethoxy saline) with
zirconium oxide and barium titanate nano fillers.

Restorative Dentistry 23
J Bagh College Dentistry Vol. 23(3), 2011 Evaluation the effect of modified

Table 1: Some of the materials that were used.

Material Trade Manufacturer
1. Zirconium (IV) oxide ZrO2 nanofiller 544760 Sigma-Aldrich Germany
2. Barium titanate BaTiO3 nano filler 467634 Sigma-Aldrich Germany
3. Trimethoxysilylpropyl methacrylate 98% Silane .440159 Sigma-Aldrich Germany
4. Toluene solvents GCC , U.K.
5. Heat-curing resin for denture . Superacryl plus Spofa Dental Czechoslovakia

Typical process was as follows nanofiller by analyzing the characteristic

30g of nano filler and 200ml pure toluene were
placed into a flask then sonicated at ambient
temperature for 20min (Figure 1.). After that, the
nano filler and toluene were placed into a flask
equipped with a magnetic stirrer(LABINCO, BV
Model L-81) at room temperature. Then 1.5g of
silane (5% wt to nano filler) was added
dropwisely by sterile syringe under rapid stirrer.
The flask was covered by parafilm and the slurry
was left standing in flask for 2 days. The solvent
(toluene) was removed by rotary evaporator under
vacuum at 60°C at rotary 150 rpm for 30 min (RE
510, Yamato, Japan).
Figure 1: Probe sonication apparatus
After that the modified nano filler was dried in
vaccum oven at 60°C for 20 hours (Gallen bamp,
England). Then nano filler stored at room
temperature before use.(4,8) . The infrared (IR)
spectra were performed (Shimadzu, FTIR-8400 S,
Japan) to determine whether or not functional
groups of the TMSPM have been attached to the
vibrations of functional groups(4) .
Pilot study
Selection of proper percentage of zirconia
nanofiller (ZrO2)
Percentages of 1%, 2%, 3%, 4%, 5% and 7% by
weight were used, percentages above 7% were not
used due to change in the colour of acrylic.
Transverse strength and impact strength tests were
used.Form the result obtained 2%, 3%, 5% and
7% were selected as a percentages of modified
zirconia nanofiller that added to the polymer by
weight.
Selection of proper percentage of Barium titanate
BaTiO3 nanofillers
Percentages of 1%, 2%, 3%, 4%, and 5% were
added to acrylic by weight percentage above 5%
were not used due to change in the colour of
acrylic, the result showed a marked decrease in
the transverse and impact strength at the
percentage above 3%. Also the result showed that
percentage below 5% did not give adequate radio-
opacity (Figure 2.).Therefore, this material was
neglected in this study.
Fracture surface of specimens were tested by
scanning electron microscope (SEM) and atomic
force microscope (AFM) show random
distribution of nano- BaTiO3 particles within the
nano cluster (aggregation), non- uniformity of the
particles, this lead to decrease in the mechanical
properties.( Figure 3.

1 4

2 5

ZrO2 percentage Amount of ZrO2 Amount of polymer Amount of monomer

0% 0 12g 6ml
2% 0.240g 11.760g 6ml
3% 0.360g 11.640g 6ml
5% 0.600g 11.400g 6ml
7% 0.840g 11.160g 6ml
Figure 2: X-ray examination of specimens reinforced with BaTiO3 nano fillers.

Restorative Dentistry 24
J Bagh College Dentistry Vol. 23(3), 2011
Figure 3A: Specimens reinforced by 3wt% and 5wt% nano- BaTiO3 fillers ( SEM).
Figure 3B: Specimens reinforced by 3wt% and 5wt% nano- BaTiO3 fillers (AFM)
A.
B
Figure 4.A, B, C: Nano fillers were well dispersed in the monomer by ultrasonication
General preparation of test specimens
Three different metal patterns were constructed by
cutting stainless steel plate in desired shape and
dimension by turning machine according to the
required test. For impact strength test, a bar
shaped specimen (80mm x 10mm X 4mm) length,
width, thickness respectively (9) .For transverse
strength test, hardness test, and surface roughness
test: a bar shaped specimen (65mm X 10mm X
2.5mm) length, width, thickness respectively(10)
.For radioopacity test: a square shaped specimen
(30mmX30mmX3mm) length, width, thickness.
(11)
Mould preparation
The conventional flasking technique for complete
denture was followed.
Proportioning and mixing of the acrylic
Table 2: percentages and amounts of polymer,
monomer and zirconium oxide nanofiller powder .
Addition of fillers
Addition of modified Zirconium oxide nanofiller
powder (ZrO2) was done by weight in four
groups, includes 2%, 3%, 5% and 7% to
monomer. An electronic balance with accuracy of
(0.0001g) was used (Sartorius BP 30155,
Germany). After the addition of ZrO2 nano filler
to monomer, the fillers were well dispersed in the
monomer by ultra sonication, using a probe
sonication apparatus(Soniprep-150, England) at
120 W, 60 KHz for 3 minutes to break them into
individual nano crystals(12) as shown in the
(Figure 4.).
Restorative Dentistry
Evaluation the effect of modified
B. C.
The suspension of the monomer with ZrO2 nano
filler was immedatly mixed with acrylic powder
to reduce the possibility of particle aggregation
and phase separation. The proportion for mixing
for acrylic resin was (2.5g:1g) P/L. All materials
were mixed and manipulated according to
manufacture’s instructions. The mixing was
carried out in a clean and dry mixing vessel and
mixed by a clean wax knife for 30 second. The
mixture was then covered and left to stand until a
dough stage was reached.
Mechanical and physical tests utilized to
examine properties
Evaluation of the mechanical and physical
properties of the prepared nano composite denture
base was compared with convensional denture
base (heat cure acrylic resin).These tests are:
1-Impact strength test
Impact strength test was conducted following the
procedure given by the ISO 179 with charpy type
impact testing instrument (Impact tester N. 43-1,
INC. USA.). The specimen was supported
horizontally at it’s ends ad struck by a free
swinging pendulum which released from a fixed
height in the middle. A pendulum of 2 joules
testing capacity was used. The charpy impact
strength of unnotched specimen was calculated in
KJ/m2.
2-Microscope test
The fractured surface of the impact test specimens
were examined and photographed with 1-scanning
25
J Bagh College Dentistry Vol. 23(3), 2011
electron microscope (SEM). 2-Atomic force
microscope(AFM). For SEM, five specimens
were examined,one representing the control ,four
representing 2wt%,3wt%, 5wt %,and 7wt% ZrO2
nanocomposite , they were sputter-coated with
uniform 2µm layer of gold in a vacuum
evaporator for 2 min at 25 mA to enhance image
resolution. Fracture surface was examined in the
back scattered electron mode with an operating
voltage of 2KV. For AFM ,two specimens were
examined, one representing 5wt%,and the other
representing 7wt% of ZrO2 nanocomposite were
examined.The thickness of the specimen should
be 2 mm to be put under the probe of the
scanning.
3-Transverse strength
The test was achieved using instron testing
machine (instron corporation, 1122, canton mass),
each specimen was positioned on bending fixture,
consisting of 2parallel supports (50)mm apart, the
full scale load was 50kg, and the load was applied
with cross head speed of 1mm/min by rod placed
centrally between the supports making deflection
until fracture occurred .
4-Surface hardness test
Surface hardness was determined using durometer
hardness tester from type shore D, (hardness
tester-th 210, time group Inc. Italy) which is
suitable for acrylic resin material. The instruments
consist of blunt-pointed indenter 0.8mm in
diameter that tapers to a cylinder 1.6mm. The
indenter is attached to a digital scale that is
graduated from 0 to 100 units; measurements
were taken directly from the digital scale reading.
Five measurements were done on different areas
of each specimen (the same selected area of each
specimen), and an average of five reading was
calculated.
5- Surface roughness test
The profilometer device (Surface roughness tester
SRT-6210, England) was used to study the effect
0% 7%
2% 5%
3% 4%
Figure.5: x-ray examination of specimens
reinforced with ZrO2 nanofiller
RESULTS
The results of infra red (IR) Spectra were
obtained by analyzing the characteristic vibrations
of functional groups in TMSPM, nano-ZrO2 ,
Restorative Dentistry 26
Evaluation the effect of modified
of ZrO2 nano filler reinforcement on micro
geometry of the test surface. This device is
supplied with surface analyzer (sharp stylus)
made from diamond. Maximum distance that can
be move is 11mm .Two measurements were done
on different areas of each specimen (the same
selected area of each specimen), and an average of
two readings was calculated.
6-Radio-opacity test
Aluminum step wedge was constructed by
cutting pure Aluminum plate into desired shape
and dimension which consist of 10 stepper
beginning with 1mm thickness of aluminum with
1mm increment in each step reaching to 10mm at
the 10th steps (11) .The specimens of different
concentration are arranged over a wax plate of
10mm thickness. The addition of wax to simulate
the absorbing and scattering media of soft tissue.
An aluminum step wedge was fixed beside the
specimens for standardization of the density of the
film.The wax plates, specimens and Aluminum
step wedge were kept over the exposure side of a
35X43cm cassette type KODAK GREEN 400.A
chest x-ray meachine (Siemens polydoros Lx and
Sx 65/80 with videomed DI, Germany), 1 meter
between the source of x-ray and specimens,
machine was operated at 53 kv and 5m As,
exposure time is 0.35 second, as it is used for
normal chest radiography .The processing was
done according to manufacture’s instructions by
using KODAK RPX-OMAT processor. A light
transmission densitometer (Densonorm21i,
pehamed,France) was used to measure the
difference in the image density of all specimens
which contain different concentration ZrO2 nano
filler in comparison with standard acrylic resin
and aluminum step wedge. (Figure 5). Five
measures in different areas of each specimen was
done, and the mean of them was calculate.
modified nano-ZrO2 ,PMMA and PMMA/ZrO2
nano composite help to clarify the interaction of
nano-ZrO2 with TMSPM in one side, and
between TMSPM with PMMA on other
J Bagh College Dentistry Vol. 23(3), 2011 Evaluation the effect of modified

side.Trimethoxy silypropylmethacrylate(TMSPM) (C=O, C-O)].The result of IR spectra, (Figure 7.)

can couple the ZrO2 particle to the resin matrix indicate of chemical bonded TMSPM with
(PMMA).The result of IR spectra,( Figure 6.) PMMA [change the shape of adsorption peak of
indicate of chemical bonded TMSPM on the ZrO2 (C=C)]
surface[change the shape of adsorption peaks of

Mo
Figure 6: IR spectrum of TMSPM, ZrO2, modified nano zirconia fillers.

Figure 7: IR spectra of PMMA, modified nano-ZrO2 and PMMA/ZrO2 nanocomposite.

Mean values, standard deviation; standard error,

maximums and minimums of the tests result are
presented in Table 1-5. Table 4: Descriptive data of hardness test.
Table 1: Descriptive data of impact strength. Control 2% 3% 5% 7%
Control 2% 3% 5% 7% Mean 84,62 85,01 85,22 85,34 85,71
Mean 8,9 9,25 9,3 9,7 8.775 SD 0,875 1,249 0,785 1,113 0,872
SD 0,210 0,513 0,349 0,453 0.1419 SE 0,277 0,395 0,248 0,352 0,276
SE 0,066 0,16 0,110 0,143 0.0449 Min 82,8 82,9 84,1 83,1 84,4
Min 8,5 8,75 8,75 9 8.5 Max 85,5 86,4 86,4 87,3 87,1
Max 9,25 10,25 9,75 10,25 9
Table 5: Descriptive data of radio-density
Table2:Descriptive data of transverse test.
strength test. Control 2% 3% 5% 7%
Table 3: Descriptive data of surface Mean 1,471 1,311 1,26 1,14 0,972
roughness SD 0,008 0,012 0,011 0,011 0,008
Control 2% 3% 5% 7% SE 0,002 0,004 0,003 0,003 0,002
Mean 116 120 124 132 115 Min 1,46 1,29 1,24 1,13 0,96
SD 2,429 4,383 7,598 6,97 1.78 Max 1,48 1,33 1,27 1,16 0,98
SE 0,768 1,387 2,404 2,208 0.566
Min 112,8 111,6 115,2 117,6 112.8 SEM and AFM examination of specimens
Max 120 128 141 142 117 reinforced by 2wt%, 3wt% and 5wt% nano
Control 2% 3% 5% 7% zirconia showed well dispersion of nano-
Mean 2,337 2,33 2,339 2,342 2,345 ZrO2.While examination of specimen reinforced
SD 0,235 0,268 0,256 0,190 0,079 by 7wt% nano zirconia showed aggregation of
SE 0,074 0,084 0,081 0,060 0,025 nano-ZrO2. (Figure 8).
Min 1,84 1,74 1,96 2,04 2,24
Max 2,68 2,62 2,81 2,64 2,49

Restorative Dentistry 27
J Bagh College Dentistry Vol. 23(3), 2011
Figure 8: Specimens reinforced by 5wt% and 7% nanoZrO2 filler.(SEM)
DISCUSSION
The addition of modified nano-ZrO2 to
improve mechanical properties and to achieve
maximum radio-opacity with minimum effect on
mechanical properties. Zirconia (ZrO2) was used
because it is excellent biocompatible material also
because of being white is less likely to alter
esthetic. Silanization of the nano-filler particles
yields a better dispersion, eliminate aggregation
and improve its compatibility with organic
polymer. the addition of modified nano-ZrO2
powder increased the value of the impact strength
and transverse strength compared to control group,
5wt% group has the highest impact strength and
transverse strength, but increasing the percentage
of modified nano-ZrO2 to 7wt% lowered the impact
strength and transverse strength due to
agglomeration nano-ZrO2 . The increase in impact
strength at 5% due to the interfacial shear strength
between nanofiller and matrix is high due to
formation of cross-links or supra molecular
bonding which cover or shield the nanofillers
which in turn prevent propagation of crack. Also
the crack propagation can be changed by good
bonding between nanofiller and resin matrix (13)
,and the increase in transverse strength that occur
with addition of 2-5wt% ZrO2 nanoparticles due to
good distribution of the very fine size of
nanoparticles enable them to enter between linear
macromoleculars chains of the polymer, segmental
motions of the macromolecular chains are restrict
lead to improve transverse strength(14) . In this
study, shore (D) hardness tester was used which is
suitable for measuring the hardness of acrylic resin
.Shore durometer type (D) hardness tester eliminate
problem with elastic recovery. It was found that
hardness value increases, but statistically was not-
significant. The surface roughness of acrylic
denture base was not significantly change when
different percentages of modified nano-ZrO2 fillers
Restorative Dentistry
Evaluation the effect of modified
were added, this result may be due to that the nano-
ZrO2 particles have very small size and well
dispersion, also surface roughness test is concerned
with outer surface and not with inner surface of
composite so when small percentage of nano-ZrO2
particles were added to acrylic resin only few
particles will be involved with the surface of the
specimen. Many studies have been conducted on
radio-opacity of denture base resins, decrease in
radiographic densities mean increase in radio-
opacity. Therefore, the transmission densitometer
show reduction in radiographic density with
increase in amount of added modified nano-ZrO2
powder, while the control group shows the highest
mean of radiographic density (low radio-opacity),
the increase in radio-opacity is statistically highly
significance, there was an increase in the relative
radio opacity with the increasing of modified nano-
ZrO2 concentration. This is oboviously due to the
presence of radio-opaque modified nano-ZrO2
powder in the polymer matrix which absorbs more
radiation than polymer matrix and appears more
radio-opaque. The radio opacity that occurs due to
the present of modified nano-ZrO2 powder may be
related to the high atomic number of Zr compared
to the chemical constituent of acrylic which has
low atomic number. The absorption of X-ray by an
element is dependent chiefly on the cube of its
atomic number.
REFERENCES
1-Jagger DC, Harrison A . The reinforcement of dentures.
J Oral Rehabil 1999; 26: 185-94.
2-Mattie PA, Rawls HR .Development of radio-opaque
auto-polymerizing dental acrylic resin. J Prosthet 1994;
3:4: 213-8.
3-Jordan J, Jacob KL, Shart MA . Expermental trends in
polymer Nan composites-Areview. Mater Sci Eng
2005;393:1: 1-11
4- Shi J, Bao Y, Huang Z .Preparation of PMMA-
nanomater calcium carbonate composites by in-situ
28
J Bagh College Dentistry Vol. 23(3), 2011
emulsion polymerization. J zhejiang University Sci
2004;56:709-13.
5- Liu-Synder P, Webster TJ .Developing a new
generation of bone cements with nanotechnology. Clin
Trend Nanotech 2007 in press.
6-Avella M, Errico ME. PMMA based nano composites
filled with modified CaCo3 nanoparticles. Macromolecular
symposia 2009; 247:1:140-6.
7-Wei G, Ma PX .Structure and properties of nano-
hydorxyapatite/ polymer composite Scaffolds for bone
tissue engineering. Biomaterials 2004;25: 4749.
8-Ayad NM, Badawi MF, Fatah AA .Effect of
reinforcement of high impact acrylic resin with micro-
Zirconia on some physical and mechanical properties.Rev
Clin Pesq Odontol 2008;4:3:145-151
9-ISO 179-1 .International organization for
standardization;2000.
Restorative Dentistry
Evaluation the effect of modified
10-American Dental Association Specification No.12
.Guide to dental materials and devicies. 10th ed.
Chicago;1999. p.32.
11-American Dental Association, Specification No. 57.
Guide to dental materials and devicies.11 ed Chicago
;2000.
12-Mohammed A, Solhi l, Nodehi A, Mirabedini SA,
Akbari K, Babanzadeh S .PMMA-grafted nano clay as
novel filler for dental adhesives. Dent Mater 2009;25:339-
47.
13-Sun L, Ronald FG, Suhr J. Energy absorption
capability of nano composites: A review. compo Sci Tech
2009;69:2392-2409.
14-Katsikis N ,Franz Z, Anne H, Helmut M .Thermal
stability of PMMA/ Silica nano- and micro composites as
investigated by dynamic-mechanical experiments. Polym
Degrad Stabil 2007;22: 1966-76.
29
J Bagh College Dentistry Vol. 23(3), 2011 The effect of low shrinkage

The effect of low shrinkage dental composite on the

fracture strength of weakened premolar teeth (An in vitro
study)
Rasshaa I. Suhail B.D.S.,H.D.D.(1)
Ali H. Al –Khafaji B.D.S., M.SC. D. (2)

ABSTRACT
Background: The aim of the study was to evaluate and compare the fracture resistance of weakened maxillary
premolar teeth with MOD preparations restored with low shrinkage new Silorane based composite (Filtek p90) in
comparison to low shrinkage methacrylate based composite (1-packable Filtek p60,2- nanohybrid Tetric Evoceram ).
Materials and Metods: Fifty human adult maxillary premolar teeth recently extracted for orthodontic purpose were
selected. These teeth received MOD cavity preparations with no proximal boxes. The teeth were then randomly
divided in to five groups (n=10), according to the material used for restoration: Group A (Teeth were not prepared ),
Group B (Teeth, with MOD cavity preparation were not restored.) Group C (Teeth, with MOD cavity preparation were
restored with Filtek p60 packable composite), Group D (Teeth, with MOD cavity preparation were restored with Tetric
Evoceram nanohybrid composite) Group E (Teeth, with MOD cavity preparation were restored with Filtek p90 silorane
based composite). These specimens were then stored in an incubator at 37Ċ for one week, at 100% humidity in
deionized water before test. Cuspal fracture resistance was determined using compressive testing machine.The
fracture specimens in group C,D and E were stained with 1%methylene- blue dye for 24 hours then examined by
stereo microscope ×40 to evaluated the mod of failure, the data were staistically analyzed using Analysis of variance
test (ANOVA), LSD test and student t-test .
Results: The results showed that there’s a high significant improvement of the fracture resistant of restored teeth using
posterior composite as compared to the unrestored ones, but; ther’s no difference of the type of the posterior
composite material used on the fracture resistance of the weakened teeth, while the sound teeth remained the
strongest teeth compared with all the other groups. Examination of the fractured specimens of GC, G D and G E
using stereo microscope revealed that for Group C and group D,70%and 50% cohesive failure respectively while for
group E 70% showed adhesive failure.
Conclusion: Posterior composite resin restoration whatever material type used for packing it, showed a great
improvement in the resistance to cuspal fracture, Silorane based composite show little improvement in fracture
resistance by means value in comparison to methacrylate based composite although statistically there is no
significant difference between them.
Key words: low shrinkage composite, fracture strength of teeth, silorane based resin composite. (J Bagh Coll Dentistry
2011;23(3): 30-36).

INTRODUCTION
With the constant evolution of tooth-
coloured restorative materials, material properties
serve as a bridge between the fundamental
material sciences and clinical applications (1).
Although dental materials have undergone
significant improvements, today’s methacrylate-
based composites still have shortcomings that
limit their applications. Two main motifs of these
limitations involve the wear phenomena and
polymerization stress. During polymerization,
shrinkage may stress the adhesively placed tooth
colored restoration while it functions within the
complex oral environment through mastication
and temperature fluctuations (1) .With the passage
of time, wear, fatigue, and internal stress–strain
from thermal contraction and expansion may
create plastic deformation and marginal leakage
and subsequently increase the risks of cuspal
(1)MSc. student, department of conservative Dentistry, University
of Baghdad
(2) Professor, department of conservative Dentistry, University of
Baghdad
deflection, secondary-caries formation, and pulpal
inflammation (2). It is striking, that during these
decades of improvement, polymerization
shrinkage was only incrementally reduced to a
somewhat lower level. Reducing the
polymerization shrinkage of composite materials
without compromising physical and handling
properties remained the major challenge for
material scientists. Efforts to improve clinical
performance and to diminish external deformation
and internal stress of methacrylate-based
composites have been focused on the
development of innovative monomers, such as
ring-opening siloranes(2). Siloranes are a totally
new class of compounds for the use in dentistry.
The name silorane derives from its chemical
building blocks siloxanes and oxiranes. Siloxanes
is well known in industrial applications for their
distinct hydrophobicity. The oxirane polymers are
known for their low shrinkage and the outstanding
stability toward many physical and
chemophysical forces and influences. The
combination of the two chemical building blocks

Restorative Dentistry 30
J Bagh College Dentistry Vol. 23(3), 2011 The effect of low shrinkage

of siloxanes and oxiranes provides the
biocompatible, hydrophobic and low-shrinking
silorane base of Silorane low shrink posterior
restorative. This innovative resin matrix
represents the major difference of Silorane
restorative compared to conventional
methacrylates. Also, the initiating system and the
filler were adapted in order to provide the best
performance of the new technology(3).
MATERIALS AND METHODS
The materials used were (Filtek P60 packable
composite , Tetric Evo Ceram, .Silorane based
composite Feltek p90 , Adper single bond ,
ExciTE, Silorane adhesive system, 37% wt
phosphoric acid etchant gel , distal water, self -
cure acrylic resin , impregum soft polyether
impression material light body consistency-
Hydrophilic, compressive testing machine
(Leybold Harris, Mode l36110, England), weight
scale, stereo microscope, modified dental
syrveyor, high speed hand piece, conventional
hand piece, vernier, metal casting ring (parallel
sided), light cure unite, (QD) as power supply,
Ash no.6, amalgam carver, amalgam burnisher,
sticky wax, amalgam condenser , hatchet,
stainless steel ½ round burs and fissure bure no.
53, tungsten carbide parallel sided fissure bure
no.330, silicon rubber finishing bure , diamond
finishing bure no.18.
Preparation of specimens
Fifty human adult maxillary premolar teeth
extracted for orthodontic purposes were collected.
To simulate the periodontium root surfaces for all
teeth dipped in to molten sticky wax to a depth of
2mm below the facial cemento enamel junction to
produce 0.2-0.3 mm layer approximately equal to
the average thickness of the PDL ligament, teeth
were then mounted in an autopolymerizing acrylic
resin blocks which’s confined in a casting metal
ring, parallel to the sides of the mould for
mounting; the parallelism was done using the
surveyor. Each tooth was removed from the resin
block when the polymerization was observed. The
wax spacer then removed from the root surface
and from the alveolus of the acrylic blocks.
Polyether impression material was delivered in to
the resin alveolus the tooth was then reinserted in
to the test blocks, and polyether material allowed
to set. Excess polyether was removed to provide
flat surface 2mm below the facial CEJ of each
tooth (4).
Cavity preparation
All of the teeth except for group A , received
MOD cavity preparation with no proximal boxes.
A width of one third of the intercuspal distance
was chosen for cavity width (figure1). The facial
and lingual walls of the cavity were prepared
parallel to each other using the modified dental
surveyor and cavosurface angle of the proximal
walls was kept at 90 degree (4). The cavity depth
was prepared to 5mm from the tip of the facial
cusp the preparation was made by using the
parallel sided carbide fissure bur No.330 of
1.6mm width with a high speed hand piece, and
appropriate hand instruments, for development of
internal detail and finish enamel margins(5).

Table 1: Composition of Adhesive systems used in this study.

Composition Manufacturer
Super etch
37%phosphoric acid etchant gel SDI, Australia
3M Dental
HEMA, ethanol, water, bis-GMA, functional copolymer of
Adper Single Bond Products
polyacrylic and polyitaconic acids
(USA)
Silorane System Adhesive Phosphorylated methacrylates, 3M Dental
Self-Etch Primer: Vitrebond copolymer,BisGMA, HEMA,Water, Ethanol, Silane- Products
treated silica filler,Initiators, Stabilizers (USA)
Silorane System Adhesive Hydrophobic dimethacrylate, 3M Dental
Bond: Phosphorylated ,methacrylates Products
, TEGDMA, Silane-treated silica filler, Initiators, Stabilizer (USA)
phosphonic acid acrylate, HEMA,dimethacrylate, highly
ExciTE dispersed silicone dixoide, initiators,stabilizer Ivoclar Vivadent

Restorative Dentistry 31
J Bagh College Dentistry Vol. 23(3), 2011 The effect of low shrinkage

Table 2: Manufacture’s scientific documentation for the composite restorative material used in this study.
Product Filtek p90 Filtek p60 Tetric Evoceram
3M Dental
Manufacturer 3M Dental product(USA) Ivoclar vivadent
product(USA)
Composite Packable
Micro-hybrid compsite Nano-hybrid composite
type composite
Method of Visible light
Visible light cure Visible light cure
activation cure
Silorane (or) ;3,4 Bis-
Resin
Epoxycyclohexylethylcyclopolymethylsiloxane, bis- GMA,UDMA Bis-GMA, UDMA
components
3,4 Epoxycyclohexy- lethyl phenylmethylsilan and Bis-EMA
Barium glass, ytterbium
trifluoride, Ba-
Filler type Quartz, yttriumfluorid Zirconia/silica
Alfluorosilica- te, glass,
SiO2
40nm and
Particle size 0.1-o.2µm 0.01-3.5 µm 3µm(3,000nm)mean
particle size(550nm)
Filler loading
76% / 53% 77% /60% 76% / 55%
wt/vol

A round bur No. ½ attached to an angled
hand piece running in a conventional speed along
the internal line angles making the roand
a sharp hatchet was used to give t he final
finishing of the enamel margins (5).
Figure1: Dimensions of the cavity
preparation, isthmus width one third of
facial-lingual intercuspal distance; cavity
depth 5mm from the tip of the facial cusp.
Sample distribution :
Group A : Ten specimens, sound were not
prepared (control group )
Group B : Ten specimens, with MOD cavity
preparation were not restored.
Group C: Ten specimens, with MOD cavity
preparation restored with filtek P60 packable
composite using adper single bond 2 bonding
agent .
Group D: Ten specimens, with MOD cavity
preparation restored with Tetric EvoCeram
composite using Exite bonding agent.
Group E: Ten specimens with MOD cavity
preparation restored with Siloren composite using
silorane adhesive system.
Restorative procedure :
Group A: sound teeth.
Group B: left without restoration.
Group C, D, and E will be prepared to receive
composite resin materials.
GC: Enamel and dentin etched with 37% wt
phosphoric acid (etch gel )for 15 second The
etchant gel then removed with water spray for 10
seconds. The excess water blotted using a cotton
pellet. Immediately after blotting excess water;
two coats with fully saturated brush tip of single
bond2 adhesive was applied on to etched tooth
surface for 15 seconds with gentle agitation, then
gently air dried for 5 seconds to evaporate
solvents and light cured for 10 seconds, then
filling the cavity with Filtek P60.
GD: Enamel and dentin etched with 37% wt
phosphoric acid (etch gel )for 15 second The
etchant gel then removed with water spray for 10
seconds .the excess water blotted using a cotton
pellet. Saturate enamel and dentin with generous
amount of Exite bonding and agitate the adhesive
on the prepared surfaces for at least 10 second
then gently air dried for 5 seconds to evaporate
solvents, light cured for 10 second seconds then
filling the cavity with Tetric Evoceram.
GE: Immediately after blotting excess water,
apply the p90 system adhesive _self-etch primer
to the entire surface of the cavity. Use a gentle
stream of air until the primer is spread to an even
film and does not move any longer. Light cure the
primer for 10 seconds. Then apply the p90 system
adhesive_bond to the entire area of the cavity and
use a gentle stream of air until the bond spread to
an even film and does not move any longer. Light
cure the bond for 10 seconds. Then filling the
cavity with Filtek P90.

Restorative Dentistry 32
J Bagh College Dentistry Vol. 23(3), 2011
The cavity in GC, GD and GE was build up
using two incremental layers each increment of
1.5mm. The first layer of 1.5mm, was adapted
using special plastic instrument applying 400gm
force, then cured for 40 seconds from occlusal
direction by putting the tip of the cone in contact fracture specimens in group C,D and E were
with the tips of the cusps. The final layer was
placed in a manner that the cavity was being
overfilled, force applied was adjusted at 400gm,
and then it was scalped and carved with proper
instruments to have a final occlusal anatomy and
finally cured from occlusal direction for 40 ♦
seconds. then finished with finishing burs and
polyester finishing strips. All the specimens were ♦
stored after preparation and restoration in an
incubator at 37% C for one week, at 100 % ♦
relative humidity in a deionized water before
testing, placing specimens in water for one week
Figure 4:Cohesive mode of failure Figure5:Adhesive mode of failure
RESULTS
The descriptive statistics which represent the
mean and standard deviation of the forces
required to fracture the five groups in Kg f are
presented in table 1and (figure7). The mean value,
(206.70 Kg f)of group A which represents the
control group represents the highest value, while
the mean value (79.27 Kg f) of group B represents
the lowest value.
Table1: Descriptive statistics of values of five
groups.
G. A G .B G .C G.D G.E
Mean (kg f) 206.70 79.27 158.15 158.91 171.24
SD 42.75 21.79 33.98 30.42 29.17
SE 13.51 6.89 10.74 9.62 9.22
Min 148.1 42.9 120.1 127.7 133
Max 254.9 105.9 203.9 211.4 205.8
The statistical analysis of data by one -way
ANOVA show a statistical significant difference
(p< 0.01) among five estimations of means value.
After ANOVA the LSD test (least significant
difference) was done to identify where the
Restorative Dentistry
The effect of low shrinkage
enough for composite to reach maximum stage of
equilibrium of water sorption (6). Specimens were
tested for resistance to cuspal fracture on the
compressive testing machine (Leybold Harris,
England 36110), until the fracture occurred. The
stained with 1%methylene- blue dye for 24 hours
(7)
, to give better contrast between composite and
dentin. the specimens examined by stereo
microscope ×40(figure4,5,6) to evaluated the mod
of failure :
If the sample takes a violet stain, its adhesive
type of failure.
If the sample takes a white stain, it’s a
cohesive type of failure.
If the sample takes a white and violet stain, its
mixed type of failure.
Figure6: Mixed mode of failure.
significance did occur among the five groups,
table 2. The result in table 2 showed that between
group A (sound teeth) control group and group B
(unrestored)
There was a highly significant difference
(p<0.01). Among group A (sound teeth) and
group C, D, E, there was a significant difference
(p<0.05).
Moreover; among group B (unrestored) and
group C, D, E, there was a highly significant
differences (p<0.01). On the other hand, between
group C and group D , between group C and
group E ,between group D and group E there was
a non significant difference (p>0.05).
Student t-test was used to show comparison
between the means of forces group C and group D
considering them as one group (methacrylate
based composite)and group E (silorane based
composite).(p<0.05), table 3.
The mode of failure is observed in table 4,
for the fractured restored groups C, D, and E.
33
J Bagh College Dentistry Vol. 23(3), 2011 The effect of low shrinkage

Table 2: The LSD between groups

Group Mean difference P-value Sig.
A&B 127.42 0.000 HS
A&C 48.55 0.002 HS
A&D 47.79 0.002 HS
A&E 35.46 0.018 S
B&C -78.87 0.000 HS
B&D -79.63 0.000 HS
B&E -91.96 0.000 HS
C&D -0.76 0.958 NS
C&E -13.09 0.370 NS
D&E -12.33 0.399 NS

250

206.7
200
171.24
158.15 158.91
150
M ean

100 79.27

50

0
GA GB GC GD GE

Figure7: Bar chart of the means of fracture forces values in (kg f) for the five groups

Table 3: Student t-test between groups.

t
Group p-value
-test
2
(G.C+G.D)& G.E 0.2
.09

Table 4: Mode of failure observed in the fractured restored specimens of group C, D and E.
Groups
Group C
Group D
Group E
DISCUSSION
Bonded methacrylate based composite versus
bonded Silorane based composite :
Although the result of student t-test show
there was no significant difference between the
methacrylate based resin composite and the
silorane based resin composite, but the mean
value of fracture resistance of Silorane is higher
than that of Feltek p60 and Tetric EvoCeram this
may be explained as follow;
several studies have demonstrate that the
cusps of molars and premolars are deflected
inwards after placement of CLII composite
restorations (8). The cuspal deflection actually
occurs as aresult of composite polymerization
shrinkage that brings the cusps together as an
attempt to relief the stresses generated due to
Cohesive Adhesive Mixed
7 _ 3
3 5 2
3 7 _
contraction. Such a deflection may greatly
influence the
stress relief and the consequently reducing the
resin tooth interface gaps and deformations that
affect the micromechanical bond between the
bonding system and the tooth structure which tend
to bind the walls of the cusps together and
strengthening the remaining tooth structure. There
are several factors may influence the displacement
of cusps by the setting contraction of the
composite: 1- the elastic modulus and flow of the
composite 2- bonding system between the
composite and the tooth, and 3- the flexibility of
the tooth (9).
In 2006 Bouillagute show that the silorane
caused significantly less tooth deformation than a
methacrylate base resine composite, which is in
agreement with previous reports(10), he found that

Restorative Dentistry 34
J Bagh College Dentistry Vol. 23(3), 2011
Although siloranes exhibit low polymerization
shrinkage, they also exhibited an atypical time-
cuspal displacement curve, with a 30 s period of
no dimensional change. One hypothesis for this
behaviour is that the siloranes were slower to
polymerize, allowing time for flow of material
and stress relaxation, resulting in a lower final
degree of cuspal strain. Recent studies with
siloranes have demonstrated a polymerization
reaction with a slow onset because of time needed
for cation formation(11). Other materials in the
current studies polymerized via free radical
mechanisms, which are inherently faster . Further,
the risk that a partial debonding of the composite
material from the cavity floor has occurred cannot
be ruled out. Furthermore, tooth size, preparation
size and preparation design were all standardized
or controlled to ensure that the different cuspal
displacement curves for the materials were from
the polymerization chemistry of the materials and
not systematic artefacts (11).
Stress build-up depends on the kinetics of the
polymerization reaction. The degree of conversion
may vary in relation to the composition of the
resin material and the curing technique, and an
insufficient degree of conversion can reduce the
E-modulus and stress development (12). A lower
degree of conversion has been described for the
Silorane-based composite. Moreover, it has been
hypothesized that Filtek Silorane has a slower
polymerization that may allow enough time for
stress relaxation through material flow (13).
The mode of failure:
Oxygen has been shown to act as inhibitor of
radical polymerization for the monomer systems
and curing conditions used in dentistry.
Previously, the influence of inhibition layer on the
adhesive strength between two successive layers
has been reported to improve the adhesion by the
formation of covalent bonds within an
interpenetrating network (14). Ring opening
reaction of the Silorane is cationic polymerization
reaction where no oxygen inhibition exists on the
polymerized surface. Therefore, the bond between
the successive layers depends only on the
reactivity of the composite material. It was
hypothesized that the bond strength between the
two successive layers of Silorane would be lower
than a methacrylate- based composite. Within the
limitations of the current study this hypothesis
was not accepted as there is 70%,30% of failures
as cohesive resin in the C&D groups (Feltik p60,
Tetric Evoceram ) respectively , 30%as adhesive
and non as mixed for C group and 50%as
adhesive and 20%as mixed for D group.
Comparing them with group E which show 30%
as cohesive failure and 70% as adhesive failure
Restorative Dentistry
The effect of low shrinkage
this result support that restoring teeth with
Silorane result in increasing the flexural strength
in compare to the two other material tested. And
this result is close to the result of A. Tezvergil-
Mutluay who found that 25%cohesive failure and
75% adhesive failure for silorane .also shamma’a
found that 70%cohesive and 30%adhesive failure
for Feltik p60 .
According to Gaintantzopoulou et al., the
adhesive system used is another factor that can
also affect the mode of failure of the composites.
Self-etching adhesive systems cause more
adhesive failure than two-step adhesive systems
due to poor adhesive infiltration in to the
demineralized dentine, (15).which can create nano-
spaces in the hybrid layer, allowing water
infiltration and promoting degradation. Further
more, the combination of hydrophilic acid with
hydrophobic monomers in self-etching adhesive
systems causes a low degree of conversion of the
adhesives, increasing permeability of the hybrid
layer, and consequently, water sorption(15). These
data corroborate the results of the present study
because there was high percentage of adhesive
failure for SBC, which uses a self-etching
adhesive system. The intense degradation of the
tooth/restoration interface observed in SBC can be
justified, because the self-etching primer causes
strong inter-tubular decalcification, resulting in
the exposure of collagen fibres. However, most
dentinal tubules were still shown to be obliterated
by smear plugs. Thus, after application and
polymerization of the adhesive, a thin hybrid layer
of 1.7–2.0 mm, with few resinous tags are
observed. Spherical and angular radiopaque
quartz and yttrium– fluoride, with sizes ranging
from 2.29 to 0.04 μm and mean size of 0.55 μm ,
compose the load particles of SBC. For along
time, quartz was not used as aloud particle,
because in the past there was no grinding
technology capable of obtaining particles smaller
than 9μm . When these particles were detached
from the resin matrix, they left large empty
spaces, this led to the diminishment of their
properties(16). However, these particles provided
the composites with the best mechanical
properties, and for this reason they were
incorporated in to SBC, now with amean size of
0.5 μm . In a study done by de Carvalho Panzeri
Pires-de-Souza it was observed that many quartz
particles were visibly detached from the SBC
resin matrix, which leaves doubts about the
efficacy of the modified silane in the longevity of
the bond between the epoxy silorane matrix and
quartz. Apparently no effective and lasting bond
of the particle with the resin matrix was obtained.
Further- more, the load particles are very
35
J Bagh College Dentistry Vol. 23(3), 2011 The effect of low shrinkage

irregular, which could compromise several other 10. Weinmann W, Thalacker C, Guggenberger R.
aspects of the composite (17) Siloranes in dental composites. Dent Mater
2005;21:68–74.
11. Stansbury JW, Trujillo-Lemon M, Lu H, Ding X, Lin
Y, Ge J. Conversion-dependent shrinkage stress and
strain in dental resins and composites. Dent Mater
REFERANCES 2005;21:56–67
1. Ausiello P, Apicella A, Davidson CL. Effect of
12. Braga RR, Ferracane JL. Contraction stress related to
adhesive layer properties on stress distribution in
degree of conversion and reaction kinetics. J Dent
composite restorations -a 3D finite element analysis.
Res 2002;81:114-8.
Dent Mater 2002;18:295–303
13. Marchesi G, LorenzoBreschia, Francesc, Antoniollia,
2. Simone Deliperi; Bardwell DN. Method to reduce
Roberto Di Lenarda, Jack Ferracane, Milena
polymerization shrinkage in direct posterior
Cadenaro. Contraction stress of low-shrinkage
composite restorations. JADA 2002; 133: 243-8.
composite materials assessed with different testing
3. Wolfgang Weinmann Christoph Thalacker, Rainer G.
systems. Dent Mater 2010;26:947-53
Siloranes in dental composites. Dental Material 2005;
14. Eick JD, Smith RE, Pinzino CS, Kostoryz EL.
21 :68-74.
Stability of silorane dental monomers in aqueous
4. Franca FG, Worschech CC, Paulillo AM, Martins
systems. J Dentistry 2006;34:405-10.
LR, Lovadino JR. Fracture resistance of premolar
15. Gaintantzopoulou M, Kakaboura A, Loukidis M,
teeth restored with different filling techniques. J
Vougiouklakis G. A study on colour stability of self-
Contemp Dent Pract 2005;3(6):85-92.
etching and etch-and-rinse adhesives. J Dentistry
5. Jackson RD, Morgan M. The new posterior resins
2009;37:390–6.
and a simplified placement technique J Am Dent
16. Crumpler DC, Heymann HO, Shugars DA, Bayne
Assoc 2000; 131: 375-83.
SC, Leinfelder KF. Five-year clinical investigation of
6. Albers HF. Tooth-colored restoration 9th ed. BC
one conventional composite and three microfilled
Decker Inc Hamilton, 2002;Ch 6:82-93,Ch7:111-123
resins in anterior teeth. Dental Mater 1988;4:217–22
7. Gorgul G, Alacam T, Kivanc BH, Uzun O, Tinaz C.
17. De Carvalho Panzeri Pires-de-Souza, Lucasda
Microleakage of packable composites used in post
Fonseca Roberti Garcia, Lourenc¸ ode Moraes Rego
spaces condensed using deferent methods. J Contemp
Roselino, Lucas Zago Naves. Colour stability of
Dent Pract 2002; 2(3):23-30.
silorane-based composites submitted to accelerated
8. Lutz F, Krejci I, Barbakow F. Quality and durability
artificial ageing—An in situ study. J Dent 2011; 03:
of marginal adaptation in bonded composite
1010-6.
restorations. Dent Mater 1991; 7: 107-13.
9. Suliman AA, Boyer DB, Lakes RS. Polymerization
shrinkage of composite resins comparison with tooth
deformation. J Prosthet Dent 1994;71:7-12.

Restorative Dentistry 36
J Bagh College Dentistry Vol. 23(3), 2011 Push out bond strength

Push out bond strength of different obturation systems

(An in vitro study)
Yasameen H. Motea Al- Ani B.D.S., M.Sc.(1)
Hussain F. Al-Huwaizi B.D.S., M.Sc., Ph.D.(2)

ABSTARCT
Background: The bond strength of the root canal sealers to dentin seems to be a very important property for
maintaining the integrity and the seal of root canal filling. The aim of this study was to evaluate the shear bond
strength of four different obturation systems using push-out test.
Materials and methods: Forty straight palatal roots of the maxillary first molars teeth were used in this study, these
roots were instrumented using crown down technique and ProTaper system, instrumentation were done with copious
irrigation of 2.5% sodium hypochlorite and 17% buffered solution of EDTA was used as final irrigant followed by distilled
water, roots were randomly divided into four groups according to the obturation system (ten teeth for each group):
Group I: AH26 sealer and lateral condensation technique, Group II: AH26 sealer and single cone obturation
technique, Group III: AH26 sealer and thermafil obturation technique and Group IV: RealSeal SE sealer and lateral
condensation technique, the roots then stored in moist environment at 37°C for one week The roots were
embedded in clear acrylic resin and each root sectioned into three levels apical, middle and cervical. The
measurement of each section was taken to prepare the supporting jig for the sections and the punch used in push-
out test, the bond strength was measured using computerized universal testing machine each section fixed in the
machine so that the load applied from apical to cervical direction at 0.5mm/min. speed and the computer drew
curve to show the higher bond force before dislodgment of the filling material. These forces were divided by the
surface area to obtain the bond strength in MPa.
Results: Statistical analysis was performed and the result showed avery highly significant differences between the four
obturation systems at each level and there were non significant differences between all level apical, middle and
cervical within each obturation system except a significant difference found between cervical and apical level in
single cone obturation system.
Conclusion: This study showed that the shear bond strength of AH26 sealer was higher than RealSeal SE sealer when
the same obturation technique was used. The shear bond strength was affected by the obturation technique and
lateral condensation technique showed higher bond strength than thermafil and single cone obturation technique
when the same type of sealer was used and the bond strength was not or little affected by the tooth level.
Key words: bond strength, push-out test, endodontic sealers, obturation systems. (J Bagh Coll Dentistry 2011;23(3): 37-
43).

INTRODUCTION
The American Association of Endodontics
defines root canal obturation as "the three-
dimensional filling of the entire root canal system
as close to the cementodentinal junction as
possible". Over the past century, numerous
obturation materials and delivery techniques have
been introduced in an attempt to obtain a
microbiologic barrier within the confines of the
root canal system, the continued research on
obturation materials is based on the concept that the
primary cause for failure of root canal treatment is
the apical migration of microorganisms and their
byproducts in a poorly filled and leaking root
canal obturation (1). Sealer should demonstrate
adhesive properities to dentin, decreasing chance
of endodontic treatment failure, increased adhesive
properities to dentin may lead to greater strength
of restored tooth, which may provide greater
resistance to tooth fracture and clinical longevity
of endodontically treated tooth (2).
(1) M.Sc. Student, Department of Conservative Dentistry,
College of Dentistry, University of Baghdad.
(2) Professor, Department of Conservative Dentistry, College
of Dentistry, University of Baghdad.
Recently, manufacturers have further
incorporated adhesive dentistry in endodontics by
introducing obturation systems with a specific focus
on obtaining a "monobloc" in which the core
material, sealing agent and root canal dentin form
a single cohesive unit. Examples of systems that
advertise this technology include a dual-curable
methacrylate resin sealer composed of filler of
calcium hydroxide, barium sulphate, barium glass
and silica (Epiphany system) has been developed for
use with self-etching primer and in association
with new thermoplastic synthetic polyester
polymer-based root canal filling material
(Resilon) that replaces gutta- percha (3).Obturation
using the Epiphany/Resilon system is claimed to
create a tight seal with the dentinal tubules
within the root canal system. In essence, it
produces a"monobloc" effect, where the core
material (Resilon), sealer (Epiphany, Realseal) and
dentinal tubules become a single solid structure (4).
Shipper et al.(5) suggested that this monoblock
would be highly desirable to provide a thorough
seal of the root canal system as it would be able to
minimize coronal leakage in case of loss or

Restorative Dentistry 37
J Bagh College Dentistry Vol. 23(3), 2011
fracture of the temporary coronal restoration, an
in vitro studies have demonstrated a good
resistance of the Epiphany / Resilon monoblock
system to bacterial leakage.
Epoxy resin - based cements have also
presented a good performance as root canal sealer
and had been shown to have low solubility ,
disintegration and a good adhesion (4).
Gutta-percha is commonly used with various
techniques to enable the dentist to accurately and
thoroughly obturate root canal system (6).Various
techniques have been suggested for root canal
obturation.
The evaluation and comparison of current
obturation techniques is therefore important in
determining there relative efficacy in achieving
an optimal seal.
MATERIALS AND METHODS
Forty freshly extracted maxillary first molar
teeth with straight palatal root canals and mature
apices were selected for this study from the
clinics of the University of Baghdad, college of
Dentistry. The age (18-45 years) while the
gender, pulpal status and reason for extraction
were not considered and criteria for teeth selection
included the following : straight root canal and
round cross section,mature, centrally located
apical foramen, Patent apical foramen, roots
devoid of any resorptions, cracks or fractures
and the roots would be 10 mm in length.
Samples preparation
After extraction, all teeth stored in distilled
water at room temperature. Any soft tissue
remnants on the root surface were removed with
sharp periodontal curette and the root surfaces
were verified with a magnifying eye lens (X 10)
and light cure device for any visible cracks or
fractures. Using a diamond disc with straight
handpiece and water coolant the palatal roots of
teeth sectioned perpendicular to the long axis of
the root at the furcation area to facilitate straight
line access for canal instrumentation and filling
procedure.The pulpal tissue was removed by
using barbed broach and the exact location of the
apical foramen and the patency of the canals were
verified by insertion of a No.10 K-file into the
canal and advancing until it was visualized at the
apical foramen. The correct working length was
established by subtracting 1 mm. from this
measurement.The roots held with a Silicon rubber
base (heavy-body) was mixed (base and catalyst)
according to manufacturer instruction and inserted
in plastic containers then the sectioned root was
inserted inside the rubber base. Heavy body was
left to set forming a small block to facilitate
handling of the roots during instrumentation and
Restorative Dentistry
Push out bond strength
obturation technique.
The canals were prepared with crown down
technique using ProTaper system (SX to F4). A
total of 10 ml of 2.5% of sodium hypochlorite
(NaOCl) was used for irrigation during
instrumentation then followed by irrigation with
5 ml EDTA 17% for 1 minute to remove smear
layer followed by 5 ml of distilled water to avoid
development of NaOC1 crystals. The roots dried
with paper point after instrumentation, canal
preparation considered complete when canal
walls were glassy smooth.
Samples grouping
The roots were randomly divided into four
groups of ten roots each.
Group I:
In this group, the AH26 silver free sealer
was mixed according to the manufactures
instructions, on a dry clean glass slab with a
spatula. The mixture had a homogenous creamy
consistency with string out at least 1 inch when
spatula was raised slowly from the glass slab.
The canal of each tooth was dried using paper
point and sealer was introduced into the canal
using ProTaper paper point F4 by rotating the
paper point two times counter clock wise to coat
the canal walls by thin film of sealer.The tip of
master gutta percha cone corresponding to the last
file size #40 was dipped into the sealer and placed
into its correct position within canal, the
previously checked finger spreader size #40
inserted between the master cone and the canal
wall to within 1 to 2 mm from working length.
Spreader taper is the mechanical force that
laterally compresses and spreads gutta-percha
creating a space for an additional accessory cone.
The tip of accessory cone size #20 was dipped in
the sealer and inserted by the space left by the
spreader, this point was followed by more
spreading and more accessory cone until the
spreader could not enter more than 2-3mm into
the canal orifice.When obturation of teeth
accomplished, the excess gutta- percha removed
with heated instrument to a level (1 mm) higher
than the coronal end of roots and vertically
condensed with root canal plugger, so the gutta-
percha obturate the entire canal.
Group II:
In this group, the root canals were coated
with sealer in the same manner described in
group I. The tip of master gutta-percha cone F4
corresponding to the last file size at working
length was dipped in sealer and inserted slowly in
the canal to the full working length. The excess
gutta- percha was removed with heated instrument
to a level (1 mm) higher than the coronal end of
roots and vertically condensed with root canal
38
J Bagh College Dentistry Vol. 23(3), 2011
plugger, so the gutta-percha was obturated the
entire canal.
Group III:
In this group, the root canals were coated
with sealer in the same manner as Group I then
the canal was obturated by Thermafil obturation
according to manufacture instruction. The
Thermafil obturator size #40 was heated in
ThermaPrep plus oven and the time required and
the temperature to which the cones were heated
was predetermined in the oven by manufacture
then the warmed obturator were inserted firmly
and slowly to the working length without any
twisting or rotation.The handle of the carrier was
cut at orifice with high speed inverted cone
diamond bur. The gutta percha, which was still in
the thermoplasticized phase, was vertically
compacted around the carrier with a hand plugger.
Group IV:
In this group, the dual syringe (with mixing
tip) was used to express the sealer onto the mixing
pad then the RealSeal sealer was carried to the
canal in small amounts on paper point according
to manufacture instruction. After the placement of
the RealSeal sealer in to canal, the Resilon master
cone size #40 was coated with the sealer and
placed into its correct working length within
canal. An endodontic stainless steel finger
spreader size #40 was inserted between the master
cone and the canal wall using firm apical pressure
only to within 1 to 2 mm from the working length.
Spreader taper is mechanical force that laterally
compresses and spreads Resilon point and
creating space for an additional accessory cone.
The tip of accessory cone size #20 was dipped in
the sealer and inserted into the space left by the
spreader, this point was followed by more
spreading and more accessory cone until the
spreader could not enter more than 2-3mm into
the canal orifice.The excess Resilon was seared
off with a hot instrument and vertically condensed
with endodontic plugger then the coronal third
cured using light curing device for 40 second
according to manufacturer instruction.
After obturation, the obturated roots of all groups
removed from the rubber base materials and
radiographed to verify the proper condensation of
the obturants, then 1 mm. of the filling materials
removed from the obturated roots of all groups to
create space for the temporary filling materials
and the all the roots sealed with glass ionomer
cement as temporary restoration. All Obturated
root were wrapped in saline moistened guaze in
closed plastic vial allowing the sealer to set for 7
days with 100% humidity at 37ºC in an incubator.
Root sectioning
After the storage period the samples were
Restorative Dentistry
Push out bond strength
embedded in clear orthodontic resin. Two ml
disposable plastic syringes was used as molds into
which the freshly prepared acrylic paste loaded, the
flat coronal end of the obturated roots would be
fixed on the face of the plastic piston of the
syringes with a resin adhesive as recommended by
the manufacturers so that the roots would be almost
centrally located within the acrylic blocks and to
ensure that the sectioning would be almost
perpendicular to the long axis of the roots. The
acrylic was prepared by mixing powder and liquid
as recommended by the manufacturers in a
porcelain jar. The material was left undisturbed for
few minutes until it reached the workable stage.The
syringe loaded with the freshly prepared workable
acrylic paste, the piston of the syringe with the
root fixed on it's face was pushed into the acrylic
paste with gentle pressure to allow the complete
embedding of the root into the acrylic and to allow
the escape of the access material through the
opened syringe tip. The material was allowed to
cure under cooled water 20°C at 10kg of
pressure, which was necessary to compensate for
the anticipated rise in the temperature of the samples
subsequent to the exothermic curing reaction of the
cold cure resin. The acrylic molds were allowed to
cure completely for at least 30min as recommended
by the manufacturers. After complete curing of the
acrylic molds the plastic syringes were cut off using
diamond disc. Using diamond disc mounted on
straight hand piece and engine with a rotation speed
regulator, the hand piece was assembled in a cutting
device. The root was cut horizontally into four
sections of 2mm in thickness and the last apical
2mm section was discarded, the cuts were made at
7.0,4.5,2.0 mm from true anatomical apex, the cuts
were made with flow of cold water (19-25°C) to
minimize smearing. Although the diamond disc was
0.4mm in thickness it actually made a cut 0.5mm
thick.
Push-out test
Each section was positioned in a reflected
light microscope and pictures of both sides of
each slice was taken with a digital camera and the
measurements calculated using AutoCAD
program, on the coronal side of the slices, the
larger diameter was measured to select a support
jig with a large enough hole (3mm) to provide
clearance for the obturating material when it
dislodged from the tooth slice. On the apical side
of the slices, the smallest diameter measured to
select a punch to be used to supply load with that
side, making sure that the punch would not
contact the dentin around the obturating material,
causing a crack and erroneous results, the punch
were 0.2mm away from the dentin wall, three
punches were used (1mm, 0.6mm, 0.4mm) for
coronal, middle and apical section respectively.
39
J Bagh College Dentistry
The thickness of each slice measured by means of
digital caliper (2 mm.) These measurements and
the perimeter measurements used by the computer
in the push-out test to calculate the bonded area
Each specimen was attached to a support metallic
jig with clearance for the dislodged material with
the coronal end facing the support jig and the
apical end facing the load cell, the punch fixed to
the microcomputer electrical control Universal
Testing Machine (WDW50). The punch will
move down ward apicocoronally (Fig 1&2) at a
crosshead speed of 0.5 mm per minute until the
first dislodgment of the obturating material. The
punch would be positioned so that it only contacts
the specimen’s obturation site, generating shear
stresses on the areas to be debonded (7). The
machine connected to computer that drew a
load/time curve which gave the maximum failure
load in kilo Newton and used to calculate the
pushout bond strength in Megapascale (MPa)
from the following formula(8):
bond strength(MPa)=load (N) /adhesion area of filling(mm^2)
The bonded (adhesion) area of each section was
calculated as the follow:
(π r1+π r2) *L . (L) was calculated as the follow:
L= √(r1-r2)^² + h^²
Where r2 the coronal radius, r1 the apical radius,
π =3.14 and h the thickness of the section.
Figure 1: Scheme for push out test.
Figure 2: Push out test.
Restorative Dentistry
Vol. 23(3), 2011 Push out bond strength
RESULTS
From the present study the following results
obtained (Table 1): the highest and the lowest
mean values for sealer push-out bond strength
were seen at cervical level of lateral condensation
technique and AH26 sealer (7.2461) and apical
level of lateral condensation technique and
RealSeal sealer (2.8921) respectively. The rest
mean values for study groups were fluctuating
between these values.
To compare between the four obturation
systems at each level ANOVA test was preformed
to identify the presence of statistically significant
differences for sealer push-out bond strength
between different obturation systems within each
level, very highly significant differences
(p≤0.001) were found at all levels. The least
significance difference test (LSD) was performed
to evaluate the significant differences between
each two obturation system at each level and the
results showed the follow: 1. There were very
highly significant difference between group I
(obturated by AH26 sealer and lateral
condensation technique) and other three groups at
all levels (apical, middle, cervical). 2. There were
very highly significant difference between group
II (obturated by AH26 sealer and single cone
obturation technique) and group III (obturated by
AH26 sealer and Thermafil obturation technique)
at apical level, highly significant (p≤0.01)
difference at middle and cervical level.
3.There were non significant difference
(p≥0.05) between group II (obturated by AH26
sealer and single cone obturation technique ) and
group IV (obturated by RealSeal\ Resilon
obturation system) at all levels (apical, middle,
cervical). 4. There were very highly significant
difference between group III and group IV at all
levels (apical, middle and cervical ).
Analysis of variance (ANOVA test) was
performed to identify the presence of statistically
significant differences for sealer push-out bond
strength between different levels within each
obturation system, non significant difference
(p≥0.05) were found within all obturation systems
except significant difference( p≤0.05) showed by
group II (obturated by AH26sealer and single
cone obturation).
The least significance difference test (LSD)
was performed to confirm the results of ANOVA
test between each two levels. The (LSD) test
showed non significant difference between the
levels within all obturation systems except group
II (obturated by AH26 sealer and single cone
obturation) showed significant difference between
the apical and cervical levels.
40
J Bagh College Dentistry Vol. 23(3), 2011 Push out bond strength

Table 1: Mean value of push-out bond this method is that it allowed root canal sealers to
strength in (MPa) & standard deviation at be evaluated even when bond strengths are low.
three levels for different obturation systems Epoxy resin-based sealers such as AH26
levels Studied groups No. Mean SD sealer (Dentsply, Detrey, GmbH, Germany) have
AH26 + lateral been widely used .AH26 sealer was selected due
10 6.5442 0.849 to its robust physical properties as the sectioning
condensation
Apical AH26 + single cone 10 2.9165 0.468 process required the sealer to lock the gutta
Level AH26 + thermafil 10 4.3627 0.738 percha cone in place(15). The result of the present
RealSeal + lateral study showed the highest mean value of push-out
10 2.8921 0.473 bond strength in obturation systems that used
condensation
AH26 + lateral AH26 sealer and when the same obturation
10 6.8375 1.053 technique was used (lateral condensation
condensation
Middle AH26 + single cone 10 3.3924 0.705 technique) there was a very highly significant
Level AH26 + thermafil 10 4.3307 0.648 difference between group I (obturated by AH26
RealSeal + lateral sealer and gutta percha) and group IV (obturated
2.9329 0.494 by RealSeal SE sealer and Resilon obturation
condensation 10
AH26 + lateral system). An explanation for these results was the
10 7.2461 1.255
condensation formation of a covalent bond by an open epoxide
Cervical AH26 + single cone 10 3.8189 0.684 ring to any exposed amino groups in collagen.
Level AH26 + thermafil 10 4.6145 0.739 Other investigations had further shown high-
RealSeal + lateral quality properties with epoxy resin– based sealers,
10 3.2192 0.416
condensation including very low shrinkage while setting and
long-term dimensional stability(16). This result
also might be related to the long setting time of
DISCUSSION AH26 sealer (9-15 hours) Which allowed
The bond strength of root canal sealers to sufficient time for sealer penetration in dentinal
dentin was important for maintaining the integrity tubules and development of good adhesion to
of the seal in root canal filling in both static and dentin. These results were in agreement with the
dynamic situations (9).In a static situation, it results of Al Ani(17) and Marilia et al.(7).
should eliminate any space that allowed the Cold lateral condensation of gutta percha in
percolation of fluids between the filling and the combination with an insoluble endodontic sealer
wall, in a dynamic situation, it was needed to remains the most widely accepted and used
resist dislodgement of the filling during obturation technique (18). In many studies, this
subsequent manipulation (10).Increased adhesive method had served as standard against which new
properties to dentin might lead to greater strength technique was often compared (19). The result of
of the restored tooth, which may provide greater this study showed the higher push-out bond
resistance to root fracture and clinical longevity of strength and there were very highly significant
an endodontically treated tooth (11).Bond-strength difference between group I (obturated by AH26
testing had become a popular method for and lateral condensation technique) and other
determining the effectiveness of adhesion between groups obturated using the same sealer AH26 but
endodontic materials and tooth structure. There different obturation technique. These results
were many methods for measuring the adhesion might be attributed that sealer thickness of lateral
of endodontic root canal sealers, but none had yet condensation technique is less than sealer
been widely accepted (12).The tensile strength test thickness in single cone obturation technique (20)
is sensitive, with the result that small alterations and there was no heat used in lateral condensation
in the specimen or in stress distribution during technique that might be affected on the bond
load application have a substantial influence on strength of sealer.
the results (13).On the other hand, a major problem The single cone obturation technique is
with shear testing is that it is difficult to closely simple and consists of placement of obturation
align the shear-loading device with the bond point that matched the instrument used in
interface. The load was offset at some distance preparation. As recommended by the
from the bonded interface, resulting in manufacturer the of the ProTaper obturation
unpredictable torque loading on the specimen (14). system the protaper gutta percha points had been
In this study, the push-out test method was used to specifically designed to match the size and the
test the dentin bond strengths of different root taper of ProtTaper files , manufacturers of
canal sealers, the model had been shown to be matched taper points claim that they could fill
effective and reproducible. Another advantage of tapered canals effectively as they correspond to

Restorative Dentistry 41
J Bagh College Dentistry Vol. 23(3), 2011
canal shape created by instruments of similar
taper (21). The result of this study showed lower
push –out bond strength value for group II
(obturated by AH26 and single cone obturation
technique ) when compared with group I and
group III both of the two groups used the same
sealer AH26 but different obturation techniques,
there was a very highly significant difference
between these groups. These results might be
related to the higher sealer film thickness of single
cone obturation technique when compared with
other obturation techniques (20).As the thickness of
the sealer increase the polymerization shrinkage
increase and the bond strength reduced.
Thermafil,core carrier technique,
demonstrated superior predictability in achieving
a homogenous, well adapted root filling with a
minimum sealer film(20,22). The results of the
present study showed that the push-out bond
strength of Thermafil obturation technique used in
group III with AH26 sealer were lower than group
I obturated by AH26 and lateral condensation
technique. These results might be related to the
effect of heat on sealer properties.
Lawson et al.(23) concluded that the
evaporation of the liquid resin component of the
sealer by heat generated during obturation
technique could result in a highly viscous sealer
that had a limited flow capacity into the patent
dentinal tubules and lower bond strength, also the
rate of polymerization may be accelerated by heat
generated during thermafil obturation technique
and increase shrinkage and decrease bond
strength. The result of this study disagreed with
Panagiotis Beltes et al.(24)who found that there
was no significant difference in AH26 bond
strength with and without heat application, this
might be related to difference in the method of
measurement bond strength, the author used
single plane shear test assembly .
One of the recent trends in endodontics had
been the development of bonded obturation
material, in an effort to provide a more effective
seal. A new material, Resilon which is the central
component of the Epiphany soft resin obturation
system (Pentron Clinical Technology) and
RealSeal (Sybron Endo), had been developed to
replace gutta percha and traditional sealer (25). The
result of this study showed RealSeal SE sealer had
lower bond strength than AH26 when the same
obturation technique used. There was a very
highly significant difference between group I
(obturated by AH26 and lateral condensation
technique) and group IV (obturated by RealSeal
sealer and lateral condensation technique). This
result is attributed to polymerization shrinkage of
the sealer, the amount of shrinkage depends on
Restorative Dentistry
Push out bond strength
the type, size, and content of filler particles as
well as the type of matrix used. The stress
associated with this shrinkage may result in
separation of the resin-based sealer from the
dentinal walls and consequently, the bond
strength value of this interface would decrease (7).
Another explanation for the lower bond strengths
detected in the groups containing a methacrylate
resin-based sealer is the effect of cavity
configuration factors (C.Factor:the ratio bonded to
unbonded surface). C-Factor is found to be
extremely high in long, narrow root canals.
Virtually every dentin wall had an opposing wall
which produces a very limited unbonded surface
area to provide relief from the stresses created by
polymerization shrinkage. It is likely the bond
between sealer core and sealer dentin is not
adequate enough to resist this debilitating stress
that develops during polymerization resulting in
gap formation (26).Another cause of lower bond
strength is resin sealer is light-cured to create an
immediate coronal seal, because this prevents
stress relief by resin flow and the resin sealer may
detach from dentin walls, thus creating interfacial
gaps and decreasing the interfacial strength (27).
These result was in agreement with Marilia et
al.(7); Matthew et al.(28) ;Ungor et al. (29) and
Andrea et al.(30).
The result of this study showed non
significant difference between all levels (apical,
middle and cervical) within each obturation
system and this result agreed with Marilia et al. (7);
Matthew .et al. (28) and Gustavo De-Deus et al.(31)
except the group II (single cone obturation
technique ) which showed significant difference
between the cervical and apical level, the bond
strength in cervical area appeared to be higher in
cervical level than apical level, this result might
be attributed to differences in sealer thickness
between the cervical and apical level when
ProTaper obturation technique is used, the
cervical level showed higher sealer film thickness
than apical level (20).
Within the limitation of the present study the
shear bond strength of AH26 sealer was higher
than RealSeal SE sealer. The shear bond strength
was affected by the obturation technique and the
bond strength were not or little affected by the
tooth levels
REFERENCES
1. Gutmann JL. Clinical, radiographic and histologic
perspectives on success and failure in endodontics.
Dent Clin North Am 1992; 36:379-92.
2. Hammad M, Qualtrough A, Silikas N. Effect of new
obturating materials on vertical root fracture
resistance of endodontically treated teeth. J Endod
2007; 33: 732-6.
42
J Bagh College Dentistry Vol. 23(3), 2011
3. Jia WT, Alpert B. Root canal filling material. United
States Patent & Trademark Office, United States
Patent Application, June 19, 2003.
4. Versiani MA, Carvalho-Junior JR, Padilha MIAF,
Lacey S, Pascon EA, Sousa-Neto MD. A comparative
study of physicochemical properties of AH Plus and
Epiphany root canal sealants. Int Endod J 2006;
39:464-71.
5. Shipper G, Ørstavik D, Teixeira FB, Trope M. An
evaluation of microbial leakage in roots filled with a
thermoplastic synthetic polymer-based root canal
filling material (Resilon). J Endod 2004;30:342-7.
6. Ingle JI, Bacland EK. Endodontic, 5 edition,
London: Hamilton, BC Decker Inc, 2002, Chp.11 (p.
575).
7. Marilia M, Keith Moore, Jeffery A Platt, Cecil E
Brown. Push-out bond strength of anew endodontic
obturation system (Resilon ∕epiphany). J Endod
2007;33:160-2.
8. Nagas E, Cehreli ZC, Durmaz V.Regional push-out
bond strength and coronal microleakage of Resilon
after different light-curing methods. J Endod
2007;33:1464-8.
9. Tagger M, Tagger E, Tjan AHL, Bakland LK.
Measurement of adhesion of endodontic sealers to
dentin. J Endod 2002;28: 351-4.
10. Ørstavik D, Eriksen HM, Beyer-Olsen E. Adhesive
properties and leakage of root canal sealers in
vitro. Int Endod J 1983; 16: 59-63.
11. Schäfer E, Zandbiglari T, Schäfer J. Influence of resin-
based adhesive root canal fillings on the resistance to
fracture of endodontically treated roots: an in vitro
preliminary study. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2007;103:274-9.
12. Gogos C, Economides N, Stavrianos C, Kolokouris I,
Kokorikos I. Adhesion of a new methacrylate resin-
based sealer to human dentin. J Endod 2004; 30:238-
40.
13. Van Noort R, Cardew GE, Howard IC, Noroozi S. The
effect of local interfacial geometry on the
measurement of the tensile bond strength to dentine. J
Dent Res 1991;70: 889-93.
14. Watanabe LG, Marshall GW JR, Marshall SJ.
Variables influence on shear bond strength testing to
dentin. In: Tagami J, Toledano M, Prati C, editors.
Advanced adhesive dentistry, Granada International
Symposium 3-4 December 1999. 1st ed. Como, Italy:
Kuraray Co, 2000. p. (75-90).
15. Hembrough MW, Steiman HR, Belanger KK.
Lateral condensation in canals prepared with
nickel titanium rotary instruments: an evaluation of
the use of three different master cones. J Endod
2002; 28: 516-9.
16. Pommel L, About I, Pashley D, Camps J. Apical
leakage of four endodontic sealers. J Endo 2003,
29(3) 208-10.
17. Al Ani M A. Shear bond strength of endodontic sealer
to dentin and gutta percha (an in vitro study).A
master thesis, Department of Conservative Dentistry,
Baghdad University, 2007.
18. Peak JD, Hayes SJ, Bryant ST, Dummer PM. The
outcome of root canal treatment. A retrospective
study within the armed forces (Royal Air Force). Brit
Dent J 2001; 190: 140-4.
19. De Deus G, Gurgel-Filho, KM. Magaihdes,
Coutinho-Filho, TA. Laboratory analysis of gutta-
percha-filled area obtained using Thermafil, System B
Restorative Dentistry
Push out bond strength
and lateral condensation, Int Endod J, 2006; 39:378-
383.
20. Al Kadhi AM. A study to evaluate the effect of
obturation technique on sealer cement thickness and
dentinal tubule penetration, A master thesis,
Department of Conservative Dentistry, Baghdad
University,2008.
21. ProTaper Obturation guide. Dentsply∕Maillefer
Swizerland , 2006.
22. Al Shimmary SA. The adaptability of three different
gutta-percha obturation techniques: Thermafil,
system B/Obtura and lateral condensation (an in vitro
study),A master thesis, Department of Conservative
Dentistry, Baghdad University, 2007.
23. Lawson MS, Loushine B, Mai S. Resistance of a 4-
META- containing, methacrylate-based sealer to
dislocation in root canals. J Endod 2008;34:833-7.
24. Panagiotis Beltes, Penny Keki, Kostas Kodonas, Chris
Gogos, Nick Economides. Effect of heat application
on adhesion of epoxy resin sealer. J Endod
2008;34:1378-80.
25. Barnett F, Trope M. Resilon. A novel material to
replace gutta-percha. J Contcmp Endod
2004;1(2):16-26. Tay F, Loushine R, Lambrechts P,
Weller R, Pashley D. Geometric factors affecting
dentin bonding in root canals: a theoretical modeling
approach. J Endod 2005;31:584-9.
27. Goracci C, Tavares AU, Fabianelli A, Monticelli F,
Raffaelli O, Cardoso PC. The adhesion between fiber
posts and root canal walls: comparison between
microtensile and push-out bond strength
measurements. Eur J Oral Sci, 2004; 112: 353-61.
28. Matthew A Fisher, David W Berzins, James K
Bahcall. An in vitro comparison of Bond strength of
various obturation materials to root canal dentin
using a push-out test design. J Endod 2007; 33: 856-
858.
29. Ungor M, Onay EO, Orucoglu H. Push-out bond
strengths: the Epiphany-Resilon endodontic
obturation system compared with different pairings
of Epiphany, Resilon, AH Plus and GuttaPercha.
Int Endod J 2006; 39(8): 643-7.
30. Andrea Gesi, Ornella Raffaelli, Cecilia Goracci, David
H. Pashley, Franklin R, Tay, Marco Ferrari.
Interfacial Strength of Resilon and Gutta-Percha to
Intraradicular Dentin. J Endod 2005; 31:11.
31. Gustavo De-Deus, Karina Di Giorgi, Sandra Fidel,
Rivail Antonio Sergio Fidel, Sidnei Paciornik. Push-
out Bond Strength of Resilon /Epiphany and
Resilon/Epiphany Self-Etch to Root Dentin. J Endod
2009; 35:1048-50.
43
J Bagh College Dentistry Vol. 23(3), 2011 Histological evaluation of intrabony

Histological evaluation of intrabony defect repair induced

by white ordinary Portland cement (WOPC)
Atheer A.Ali, B.D.S. (1)
Shatha S. Mohammed, B.D.S., Ph.D (2)

ABSTRACT
Background: recently the ordinary Portland cement (OPC) has been analyzed and compared physically, chemically
and biologically to mineral trioxide aggregate MTA and because of the similarity between OPC and MTA, So the
Possibility of using Portland cement as a less expensive alternative to MTA in dental practice should be considered. In
view of this, the Present study is to evaluate the biological response of the jaw bone to intraosseous ordinary Portland
cement (OPC) implantation.
Materials and Methods: fifteen local breed adult male rabbits divided into three groups of five rabbits, each rabbit
has receive two intrabony defects in the mandible bone, one filled with white ordinary Portland cement (WOPC), the
other left empty as a control The histological sections obtained after 1, 4 and 8 weeks postoperatively. The
histomorphometric analysis including counting of bone cells (osteoblasts & osteoclasts) ,inflammatory cell and
observation of the degree of inflammation and the type of bone reaction to OPC material.
Results there was no significant difference in inflammatory response between OPC group and control group at all
period of time, , there was significant increase of osteoblasts number at one and four weeks interval of OPC group
when compare with the control groups but at eight week there were no significant difference of osteoblasts
number between them, control group showed highly significant increase of osteoclasts number at four and eight
weeks interval when compare to OPC groups. Most of OPC group and in all period of time showed bone deposition
in direct contact with ordinary Portland cement (Type I bone reaction).
Conclusions: As a result we can conclude that the OPC material show high degree of biocompatibility, induce bone
healing and act as bioactive material.
Key words : Portland cement,intaosseos inplantation, bone biomaterial. (J Bagh Coll Dentistry 2011;23(3): 44-49).

INTRODUCTION
Ordinary Portland cement (OPC) was
invented in the early 19th century. Since then, it
has gained universal popularity with applications
covering many different fields, primarily in civil
engineering, ordinary portland cement composed
of minerals, among which the most important are
tricalcium silicate (3CaO.SiO2) ,dicalciumsilicate
(2CaO.SiO2), tricalcium aluminate
(3CaO.Al2O3) ,tetracalcium ironaluminate
(4CaO.Al2O3.Fe2O3)and di-hydrated calcium
sulfate (CaO.SO3.2H2O) which is on hydration
produce a silicate hydrate gel(C-S-H) and calcium
hydroxide (CH) (1).
In dentistry, Ordinary Portland cement (OPC)
had been investigated as a potential alternative
restorative material to the presently used materials
in endodontics which is mineral trioxide
aggregate (MTA)(2) .
Mineral trioxide aggregate (MTA) an
endodontic material used as a viable alternative
for various clinical applications, such as capping
of pulp tissue, root end closure and for repairing
furcal perforations (3).
(1) MSc student, Oral Diagnosis, College of Dentistry, Baghdad
University.
(2) PhD Professor, Oral Diagnosis, College of Dentistry,
Baghdad University.
Wucherpfenning et al (4) reported that both
MTA and Portland cement (OPC) seem almost
identical macroscopically, microscopically and by
X-ray diffraction analysis.
Estrela et al (5) investigated the chemical and
antibacterial properties of various materials
including Portland cement and MTA and found
that both cements are constituted of the same
elements, except for bismuth that added to MTA
to provide the radiopacity, Funteas et al (6)
evaluate (15) elements of MTA and Portland
cement composition, the results showed
similarities between the materials, except for the
fact that there was no detectable quantity of
bismuth in Portland cement. It was concluded that
there was no significant difference between the
other (14) elements in both Portland cement and
(MTA). Taking into account the low cost and
apparently similar properties of (OPC) in
comparison to (MTA), so it is reasonable to study
the biocompatibility of (OPC),various methods
have been suggested to evaluate materials applied
in dentistry, according to Shahi et al (7), today
there are four classical methods to assess the
biocompatibility of a material: (a)invitro
cytotoxicity assessment, (b) subcutaneous
implants, (c) intraosseous implants and(d) invivo
assessment of periradicular tissue reaction in
animals. Several invitro studies concerning the
biocompatibility of OPC had been conducted (2,8-
10)
and Few invivo studies(11-13) therefore more

Oral Diagnosis 44
J Bagh College Dentistry Vol. 23(3), 2011
invivo studies is recomended for giving evidence
supporting that (OPC) are biocompatible and may
have potential to promote bone healing
,accordingly Portland cement may become the
base of a viable dental restorative material and
possibly a material for orthopedics (2).
MATERIAL AND METHOD
Portland cement: White ordinary Portland
cement (WOPC), (197-1 CEM I) grade 52.5N. it
has been tested for their chemical and physical
properties in the national center for laboratory and
building Research in (Baghdad).(Figure 1)
Animals: Fifteen local breed adult male rabbits
divided into three groups of five rabbits, each
rabbit has receive two intrabony defects in the
mandible bone, one filled with white ordinary
Portland cement (WOPC), the other left empty as
a control, these rabbits scheduled for sacrificing
after( 1,4,8week) postoperatively.
Surgical procedures: The surgical procedures
were done under general anesthetic drugs by
using atropine sulfate at dose of 0. 4 ml / Kg body
weight I.M. as a premedication to reduce salivary
and mucous secretion, followed 10 minutes later
by a mixture of ketamin hydrochloride 10% and
xylazin 2% at a dose of 0.5,0.2 ml / Kg body
weight respectively I.M. these were injected into
the rear limb-thigh muscle of the rabbits.
Application of eye ointment to prevent dryness of
the cornea, Lidocaine hydrochloride 2% with
adrenaline 1:80,000 was infiltrated submucosally
along the planned surgical site (intraorally)(14). An
incision was made along the alveolar crest in the
naturally edentulous space between the incisors &
premolar teeth in the mandibular arch (lower
diastema) and by using slowly running hand
piece(800rpm) with round bur (no.012) cooled by
a continuous stream of sterile normal saline,we
perform the orifice in the bone ,then with fissure
bur (no.010) the cavity deepened to hold the
implanted material ,the size of the cavity
approximately 3mm in diameter and 3mm in
depth(15), The first hole (anterior) filled with white
Portland Cement which is mixed with distilled
water by ratio of 1:3 (w/c) and applied by using
amalgam carrier fig(2), The second hole(
posterior) remain empty as control, these two
holes were separated by approximately 4mm ,the
surgical flaps were reapproximated with
resorbable sutures.
Histological Preparation: After sacrificing of
rabbit ,the right diastema resected and disected
into two segment (control and experimental) ,the
specimens fixed in 10% buffered formalin for 48
hours then subjuct to decalcification with solution
of 10% formic acid for (1-2week) until
Oral Diagnosis
Histological evaluation of intrabony
satisfactory decalcification is obtained then we
perform embedding , sectioning and staining with
heamatoxiline and eosin stains and Van-gieson
stain.
Histopathological observation: Performed by
two histopathologists in a blind manner .The
defects and the adjacent related area of both the
control and experimental specimens were
examined. In each defect five separated field
within high-power of magnification (40X) were
taken for cell counting, and the microscopical
findings include,counting of cells (inflammatory
cells and bone cells (osteoblasts and osteoclasts)),
Histopathological evaluation of bone apposition
,neovascularity, type of material reaction with the
bone and degree of inflammation were assessed.
Statistical analysis: We find the; mean, standard
deviation of cell number and the significant of
difference between the groups (P-value of t-
test).(Table 1-3)
RESULTS
The Specimens were harvested in three periods:
1. One week
2. Four weeks (one month).
3. Eight week (two months).
The histological examination shows the
following findings:
After one week the histological finding of
control bony defect shows an early stage of bone
healing. The defect was filled with collagen
fibers, large number of fibroblast and new blood
vessel with moderate degree of inflammatory
response (Figure 3), while experimental defect
appears empty spaces because Portland cement
removed by decalcification process, but there is a
few amount of loose fibrovascular tissue found at
the periphery and within the WOPC material
which contains a number of blood vessels,
fibroblast cell, inflammatory cells and few bone
marrow spaces, the inflammatory response is
moderate Osteoblasts are present at the periphery
of the defect on bone surface. (Figure 4).
After four weeks the histological findings of
control bony defect shows formation of bone
trabeculea. The space between bone trabeculea
was filled with the cartilaginous callus with mild
degree of inflammatory response,osteoblasts
present at the periphery of bone trabeculea and
osteoclast also seen at this period fig(5), while
experimental defect shows bone deposition
around the defect and formation of new bone
trabeculae and bone sequestrum within the defect
few fibrovasecular tissue also present ,the
inflammatory reaction is mild large number of
osteoblasts present at the periphery of bone
45
J Bagh College Dentistry Vol. 23(3), 2011
defect ,osteoclasts is not detected at this period
(Figure 6)
After eight week the control defect filled with
lamellated bone with few spaces ,the spaces filled
with little amount of collagen fiber and few
fibroblast with scant inflammatory cells
,osteoblasts present at the periphery of bone
trabeculea with few number of osteoclast (Figure
7), the while experimental defect shows
continuous deposition of bone around the
implanted material (WOPC) in form of lamellae
and bone ingrowth toward the core of implanted
material fibro vascular tissue still present at the
periphery of defect, the inflammatory reaction is
very mild Lesser number of osteoblast than that of
second period were present at the periphery of
bone defect and new bone trabeculae,osteoclast is
rarely detected at this period (Figure 8).More than
50% of cases of experimental group among these
period of time show direct contact between bone
and WOPC.
DISCUSSION
Various methods have been suggested to
evaluate materials applied in dentistry (7)
Intraosseous implantation used to evaluate
material applied spacifically for endodontic or
intended for prolong contact with the bone (16)
International Standard Organization (ISO)
recommends bones as Tibia, femur and the
mandible of laboratory animals for material
implantation investigation and among small
animal's rabbits, rats, guinea pigs, and cats are
more popular(17). In present study the rabbit used
other than rodent because small rodents have
primitive bone structures and do not have
haversian systems. Whereas rabbits, as well as
dogs, have haversian systems that are similar to
that of man, which is an important advantage in
terms of extrapolation of results obtained with
such animals for human bone repair(18). And
unlike rodents, the rabbit's size allows multiple
collections from the same bone for testing
biomechanical or histopathological properties (19).
In this study we evaluated the bone healing
following the implantation of WOPC in
experimentally created intrabony defects in
mandible of rabbits. It should be mentioned that
the white color of the applied Portland cement
reject the possibility of its tissue tattooing in
endodontics. Portland cement composed mainly
of tricalcium silicate and dicalcium silicate which
on hydration produce calcium silicate hydrate gel
and calcium hydroxide (20). Portland cement has
been shown to have similarities to dental
materials (mineral trioxide aggregate
MTA,calcium hydroxide CaOH) used in
Oral Diagnosis
Histological evaluation of intrabony
endodontic treatment for the repair of
perforations, pulpotomies and retro-fill
preparations(21, 22, 23).
Few studies conducted concerning the bone
interaction with Portland cement after
intraosseous implantation, (11) implanted Portland
cement in mandible of guinea pigs, (12) use dogs
mandible and in study by(13) OPC included in the
skull of rats , all of these studies supported the
findings of the present investigation.
At the end of the 1st week postoperatively
Both of control and experimental groups shows
moderate degree of inflammation and this degree
reduced with time (4,8 weeks) the inflammatory
cells measurement showed no statistical
significant difference (P>0.05) between the
experimental group and the control at all interval
and Inflammatory response observed during the
first few days after surgery in all groups seemed
to be related to the surgical trauma and it has been
cited by other authors ( 24).
In present study the high alkaline pH levels
of WOPC paste seemed to induce low grade
irritation to the surrounding tissue without
harmful effect like foreign body reaction or bone
necrosis. This result agree with (2) who tested an
accelerated Portland cement(APC) invitro by
observing the cytomorphology of human
osteosarcoma cells (SaOS-2 cells) which is
"represent a highly differentiated cell line capable
of inducing bone formation and are thus a model
for osteoblastic behavior.(25) ";with the presence of
the APC and the effect of this material on the
expression of bone remodeling markers,
demonstrated evidences that these materials are
non-toxic does not cause cell death and may have
potential to promote bone healing.
Counting the bony cells (osteoblasts,
osteocytes & osteoclasts) determined the level of
the bone formation (26). At the 1st week, the t- test
showed very high significant difference between
the control and experimental groups (p<0.001) in
osteoblasts number, the experimental groups
showed large number of osteoblast cells cover the
implanted material, This reaction was not
observed in the normal healing process in control
group, this finding suggest that WOPC seemed
to induce the bone healing by supporting the
proliferation and adhesion of bone−forming cells
(osteoblasts), this is may be attributed to their
structural characteristic and mode of action. these
findings supported by (11) who reported that MTA
and Portland cement had similar properties, both
of them offered a biologically active substrate for
bone cell and this could be attributed to their
ability for allowing good adherence and
proliferation of the cells`, after four weeks the t-
46
J Bagh College Dentistry Vol. 23(3), 2011
test showed significant difference between the
control and experimental groups (p<0.05) with
greater number in experimental group than that of
control group but at eight week interval the
osteoblast mean number in both groups decrease
than that of (second period), the t- test showed
there is no significant difference between the
control and experimental groups (p=0.4), This is
in agreement with (27) who showed as time elapsed
there were reduction in the production of calcium
hydroxide as a by-product of cement hydration
reaction thus affect the proliferation of
bone−forming cells (osteoblasts) so there is
reduction of these cells number. Control group
showed highly significant increase of osteoclasts
number at four and eight weeks interval when
compare to WOPC groups(p<0.001) ,this is
indicating that the WOPC material is not
resobable and decreasing in size due to
biodegradation, this is compatible with (28) who
documented that postoperative radiographs taking
to root perforation of dogs teeth sealed with OPC
and MTA after 90 days revealed that both of them
were totally or partially dissolved in some cases
with new cementum formation on root
perforations of dogs’ teeth.
In more than 50% of cases of WOPC
intraosseous implantation there were new bone
appositions in direct contact with Portland cement
,this is supported by (29) who investigate the
interactions between white Portland
cement(WOPC) paste and simulated body fluid
(SBF) invitro and conclude that exposure to SBF
has been found to promote the precipitation of a
layer of ‘bone-like’ hydroxyapatite on the surface
of WOPC paste these results showed that WOPC
was a bioactive material which when came in
contact with tissue fluid, it would release an
abundance of Ca+2 and OH-1 which were react
with PO4-3 that present in tissue fluid leading to
the formation of hydroxyapatite crystals
[Ca10(PO4)6(OH)2]; this layer develops strong
direct chemical bond with bone ,therefore the
osteogenic activity of OPC was attributed to this
dissolution-precipitation reaction. Also the direct
bone contact with Portland cement supported by
(30)
who thought that the deposition of
hydroxyapatite layer onto the Portland cement
paste surface is attributed to both the dissolution
of calcium hydroxide and to the high proportion
of preexisting Si-OH nucleation sites presented by
the nanoporous calcium silicate hydrate gel
structure of WOPC and indicate that the likely
mechanism of bonding between WOPC paste and
viable bone tissue is the spontaneous formation of
an intermediate layer of hydroxyapatite on contact
with human plasma.
Oral Diagnosis
Histological evaluation of intrabony
While the formation of fibrous capsule in few
cases might be due to the insertion of material
was not in close contact with host bone or
possibly due to different animal individual reveals
different reaction.
REFERRENCES
(1) Richardson IG, The nature of C-S-H in hardened
cements. Cement and Concrete Research 1999;
29(8):1131-47.
(2) Abdullah D, Ford TR, Papaioannou S,
Nicholson J, McDonald F.An evaluation of accelerated
Portland cement as a restorative material. Biomaterials
2002; 23(19):4001-10.
(3) Torabinejad M, Chivian N. Clinical applications
of mineral trioxide aggregate. J Endod 1999; 25(3):197–
205.
(4) Wucherpfennig A, Green DB. Mineral trioxide
vs Portland cement: two biocompatible filling materials
[abstract]. J Endod 1999; 25:308.
(5) Estrela C, Bammann L, Estrela C, Silva R,
Pécora JD. Antimicrobial and chemical study of MTA,
Portland cement, calcium hydroxide paste, Sealapex and
Dycal. Braz Dent J 2000; 11:19-27.
(6) Funteas U, Wallace J, Fochtman EW. A
comparative analysis of mineral trioxide aggregate and
Portland cement. Aust Endod J 2003; 29:43-44.
(7) Shahi S, Rahimi S, Lotfi M, Yavari H, Gaderian.
A comparative study of the biocompatibility of three
root-end filling materials in rat connective tissue. J
Endod 2006; 32(8):776-80.
(8) De Deus G, Ximenes R, Gurgel-filho E,
Plotkowski M, Coutinho Filho T. Cytotoxicityof MTA
and Portland cement on human ECV304 endothelial
cells. Int Endod J 2005; 38:604–9.
(9) Ribeiro D, Sugui M, Matsumoto M, Marques M,
Salvadori D. Genotoxicity and cytotoxicity of mineral
trioxide aggregate and regular and white Portland
cements on Chinese hamster ovary (CHO) cells in vitro.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2006;101:258-61.
(10) San M, Hyun-Il K, Hyo-JP, Sung-H Pi, Chan-Ui
Hong. Human pulp cells response to portland cement in
vitro. J Endod 2007; 33 (2):163-6 .
(11) Saidon J, He J, Zhu Q, Safavi K, Spangberg LS.
Cell and tissue reactions to mineral trioxide aggregate
and Portland cement. Oral Surg Oral Med Oral Pathol
Oral Radiol and Endod 2003; 95(4): 483–9
(12) Dokami S, Raoofi S, Mohamad J, Hooman K.
Histological Analysis of the Effect of Accelerated
Portland Cement as a Bone Graft Substitute on
Experimentally-Created Three-Walled Intrabony
Defects in Dogs. JODDD 2007; 1(3):131-6.
(13) Fabiano S, Jose CarlosC, ReinaldoD.
Macroscopic and microscopic evaluation of Portland
Cement Joint - CP I and the Portland Cement White not
structural - CPB included in the skull of rats, Brazil,
university of saopaulo: Faculdade de Odontologia (FO).
Master theses 2009.
(14) Al–Hurr QY. Histological findings of
hydroxyapatite in experimentally induced oral and
facial bone defects in rabbits. M.Sc. Thesis College
of Dentistry Baghdad University 2001.
47
J Bagh College Dentistry Vol. 23(3), 2011
(15) Ayyam kh, intraosseous implantation of gutta-
percha, silver point and zinc oxide-eugenol based sealar
in the mandible bone of Hamster.Master Thesis,collage
of dentistry ,university of Baghdad 1996.
(16) Blackman R, Gross M.Seltzer S. An evaluation
of biocompatibility of glass-ionomer silver cement in
rat mandible. J Endod 1989; 15(2):76-9.
(17) International standards organization. ISO 10993-
6(F)-07-15. Biological evaluation of medical devices.
Part 6. Test for local effects after implantation. Geneva
1994; 1-8
(18) Nunamaker DM. Experimental models of
fracture repair. Clin Orthop Rel Res 1998; 355s:56–65.
(19) Matos M, Gonçalves R, Araújo FP.
Experimental model for osteotomy in immature rabbit.
Acta Ortopédica Brasileira 2001; 9:21–6.
(20) Camilleri J, Montesin F, Brady K, Sweeney R,
Curtis R, Pitt Ford TR. The constitution of mineral
trioxide aggregate. Dental Materials 2005; 21: 297–303.
(21) Torbinejad M, Ford TR, Abedi HR,
kariyawasam SP, Tang HM. Tissue reaction to
implanted root end filling material in the tibia and
mandible of guinea pigs. Preliminary report. J Endod
1998; 24(3):468-71.
(22) Holland R, Souza V, Murata S, Nery MJ,
Bernabé P, Otoboni Filho JA, Dezan Junior E. Healing
process of dog dental pulp after pulpotomy and pulp
covering with mineral trioxide aggregate or Portland
cement. Braz Dent J 2001;12(3): 109-13.
Figure 1: White ordinary Portland cement
Figure 2: Two holes were made the anterior filled with Portland cement the posterior remain
empty as control.
Oral Diagnosis
Histological evaluation of intrabony
(23) Camilleri J, Montesin F, Brady K, Sweeney R,
Curtis R, Pitt Ford TR.A Review of the methods used to
study biocompatibility of Portland cement-derived
materials used in dentistry. Malta Medical J 2006;
18:03-10.
(24) Reddi A, Wientroub S, Muthukumaran N.
Biologic principles of bone induction. Orthop Clin
North Am 1987;18:207-12.
(25) McQuillan D, Richardson M, Bateman JF.
Matrix deposition by a calcifying human ostegenic
osteosarcoma cell. Bones J 1995;16:415-26.
(26) Bushra H. The effect of the Iraqi propolis on
the bone healing of rabbit mandible, Master Thesis,
college of dentistry ,university of Baghdad 2007.
(27) Camiller J. Characterization and chemical
activity of Portland cement and two experimental
cements with potential for use in dentistry. Int Endod J
2008; 41: 791–9.
(28) Juarez B, Bramante C, AssisG F de, Bortoluzzi
EA. Healing of Root Perforations Treated with Mineral
trioxide Aggregate (MTA) and Portland Cement. J Appl
Oral Sci 2006; 14(5):305-11.
(29) Coleman N, Nicholson JW, Awosanya K. A
preliminary investigation of the in vitro bioactivity of
white Portland cement, Cement and Concrete Research
2007;37(11):1518-23.
(30) Torkittiku P, Chaipanich.AR. Investigation of
the mechanical and in vitro biological properties of
ordinary and white Portland cements. Science Asia J
2009; 35: 358–64.
48
J Bagh College Dentistry Vol. 23(3), 2011 Histological evaluation of intrabony

Figure 3: One week control defect Figure 4: One week experimental defect

Figure 5: Four weeks control defect Figure 6: Four weeks experimental defect

Figure 7: Eight weeks control defect Figure 8: Eight weeks experimental defect

Table 1: Statistic analysis for cell counting at one week interval

Group Control Experimental P-value
102.6 ± 31.6 82.8 ± 15.6
Inflammatory cell
0.23
Degree of inflammation
Moderate Moderate
Osteoblast cell 0.00 ± 0.00 21.8 ± 7.15 0.000***

Table 2: Statistic analysis for cell counting at four weeks interval

Group Control Experimental P-value
49 ± 12.8 38.4 ± 9.2
Inflammatory cell
0.171
Degree of inflammation
mild mild
Osteoblast cell 27.2 ± 3.8 35 ± 6.12 0.04*
Osteoclast cell 1.6 ± 0.5 0.00 ± 0.00 0.0001***
Table 3: Statistic analysis for cell counting at eight weeks interval
Group Control Experimental P-value
16.4 ± 7.8 14.2 ± 6.7
Inflammatory cell
0.64
Degree of inflammation
mild mild
Osteoblast cell 19.6 ± 5.9 23.2 ± 8.19 0.4
Osteoclast cell 3.2 ± 1.09 0.16 ± 0.16 0.000***

Oral Diagnosis 49
J Bagh College Dentistry Vol. 23(3), 2011 The prevalence of cervical

The prevalence of cervical carotid arteries stenosis and

calcifications among sample of Iraqi diabetic
postmenopausal women detected by using Doppler
sonography and digital dental panoramic tomography
Baydaa H. Hussein Al- Saleem, B.D.S., M.Sc.(1)
Lamia H. AL-Nakib, B.D.S., M.Sc.(2)

ABSTRACT
Background: Stroke is the third leading cause of death in United States today, it is also the leading cause of severe
disability (1,2). The most well-known risk factor for the development of stroke is high-degree internal carotid artery
stenosis (3). Stroke may be preventable (but the major challenge is to find effective methods of detection of stroke-
prone patients). The aim of this study was to compare the prevalence of cervical carotid arteries stenosis among
healthy and non insulin dependent diabetes mellitus Iraqi postmenopausal women sample also correlating carotid
artery calcification detected on digital dental panoramic tomography with carotid stenosis determined by Doppler
ultrasound.
Materials and methods: The Digital Dental Panoramic Tomographs was taken to the sample and observed for
presence or absence of any radiopacity in the soft tissue region at the bifurcation of common carotid artery. Many
parameters were measured by Doppler ultrasound include peak systolic velocity, peak end diastolic velocity for
Internal and common carotid arteries, Ratio of velocities for Internal Carotid/ velocities for Common Carotid and
Ratio; Measure the reduction in lumen diameter and area of Internal and Common Carotid to calculate the
percentages of Linear stenosis and area stenosis of the two arteries; detect presence of Carotid plaque in right and
left sides .
Results: The sensitivity of the diagnostic performance of Digital panoramic tomograph in predicting atheromal
plaque and final diagnosis of significant stenosis, atheromal plaque detected by Doppler in predicting final diagnosis
of significant stenosis was higher when the risk increase (higher in type II diabetic group) .No statistically significant
differences between control group and type II diabetic group regarding finding on panoramic radiograph although the
prevalence ratio in type II diabetic group higher than control . Calcification finding shows statistical significant
difference regarding being employed and age (un employed over and over 60 years subjects had more calcification).
Statistical significant difference was found between control and type II diabetic group regarding carotid atheromal
plaque finding on Doppler. Although the prevalence ratio of ffinal diagnosis of significant stenosis in type II diabetic
group 5 times higher than control group, the observed increased risk failed to reach the level of statistically significant
,also final diagnosis of significant stenosis shows statistically a significant difference regarding being
employed(employed had less) . Statistically found that there was significant differences between those had FDSS or not
in the mean of low density lipoprotien in type II diabetic group. The prevalence rate of atheroma, final diagnosis of
significant stenosis and Carotid calcifications were higher in unemployed subjects and sedentary life style.
Conclusions: The highest risk group in relation to had Carotid artery calcifications, atheromal plaque and Final
diagnosis of significant stenosis detected by Doppler ultrasound was in type IIDM group.
Encouragement of physical activity and sports may reduce the prevalence rate of atheroma, FDSS and
calcifications .The diagnostic performance of CAC detected by DDPT as a diagnostic tool for plaque detected by
Doppler and the diagnostic performance DDPT and AP detected by DUS in predicting FDSS had higher sensitivity
and PPV in type IIDM group than healthy .The dentist able to discover asymptomatic significant stenosis in patient
with carotid artery Calcification on panoramic radiograph and should refer these patients to physician for
determination the magnitude of the disease by further examination this referral had similar importance when
radiologist discover in patient atheromal plaque detected by Doppler ultrasound and do further investigation by
Doppler to determine the magnitude of the disease and find asymptomatic significant stenosis .
Key words: carotid stenosis. Doppler ultrasound. Panoramic radiograph. (J Bagh Coll Dentistry 2011;23(3): 50-55).

INTRODUCTION
Carotid arteries are the blood vessels that
deliver blood through the neck to the brain. Each
common carotid artery (CCA) bifurcated into
internal (ICA) and external carotid arteries (ECA)
(1-4)
. of stroke have therefore become of great interest.
(1) MSc student, Dental Radiology, College of Dentistry,
Baghdad University.
(2) Assit. Professor, Dental Radiology, College of Dentistry,
Baghdad University.
Stroke is one of the most common causes of
disability and the third leading cause of death in
the developed world. The identification and
treatment of factors associated with increased risk
The most well-known risk factor for the
development of cerebrovascular events is high-
degree internal carotid artery stenosis (3,5 ).Carotid
artery disease is a condition in which a fatty
material called plaque builds up inside the carotid

Oral Diagnosis 50
J Bagh College Dentistry Vol. 23(3), 2011
arteries. When plaque builds up in arteries, the
condition is called atherosclerosis (6). Carotid
atheroma is an atherosclerotic disease process that
occurs along the wall of the lumen of CCA near
its bifurcation. Pieces of atheroma may ulcerate
and break off to form an embolus that can occlude
a smaller intra cerebral artery causing stroke (7).
Not all atherosclerotic lesions are calcified;
furthermore, the presence of calcification in not
definitive indicator of vascular disease (8). Kasper
et al stated that in addition to known risk factors
for ischemic stroke (hypertension, a trial
fibrillation, DM, smoking, hyperlipidemia,
asymptomatic carotid stenosis and symptomatic
carotid stenosis (50-69% and 70-99%). The over
all risk of stroke was much greater in a high-risk
group (those with more than six risk factors) than
in a low risk group (those with less than six risk
factors) (9). The DM is a chronic metabolic
syndrome caused by relative or absolute insulin
deficiency results in elevated blood glucose levels
and produces disturbances in lipid and protein
metabolism(10).
Type II DM is a disease complex with both
metabolic and vascular components that
accelerate the development of atherosclerotic
lesions at the bifurcation of the common carotid
artery and double or triple the risk of ischemic
stroke (11). The decline of estrogen decreases low-
density lipoprotein (LDL) catabolism in the blood
and that increased LDL, cholesterol levels in the
blood were associated with hepatic lipase activity,
causing vessel walls to harden and thicken (12,13) .
There are many diagnostic techniques for
identification of stenosis such as: Angiography
diagnostic technique that carries its own risk and
expense, more over the measurements of
angiography are subject to error because the
severity of radiographic stenosis may inaccurately
reflect the true stenosis as a result of effects of the
limited planes of view used in angiographic
imaging ( 14 ,15).
Digital dental panoramic tomography (DDPT)
is capable of identifying atherosclerotic lesion in
the cervical portion of the common carotid artery,
and CCAC detected on DDPT can be used as an
aid to predict vascular strokes in these patients.
Calcification in carotid bifurcation region is
detectable on panoramic radiographs in 1% to 5%
of the adult population (8, 16).
Lesions in the extra cranial carotid arteries can
be measured non invasively by ultrasonography
and appear to reflect the extent and severity of
atherosclerosis in population groups. Doppler
ultrasound is test in which sound waves above the
range of human hearing are sent into the neck.
Echoes bounce off the moving blood and the
Oral Diagnosis
The prevalence of cervical
tissue in the artery can be formed into an image.
Ultrasound is fast, painless, risk-free, and
relatively inexpensive compared to MRA and
arteriography (17). Five types of diagnostic
Doppler instrument are usually distinguished:
continuous wave (CW) Doppler, pulsed wave
(PW) Doppler, duplex Doppler, color Doppler
imaging and power Doppler imaging (18).
MATERIALS AND SUBJECTS
Thirty Iraqi postmenopausal females 45-75
years of age were collected during the period from
August/2008 to April /2009 in Surgical Sub
Specialties in Baghdad were they subjected to
clinical investigations ,the information from each
patient were recorded in a special case sheet .
The sample grouping as follow:
Control group composed from 15 healthy females
and type II diabetes mellitus (DM) group
composed from 15 females suffer from non
insulin dependent diabetes mellitus only.
The DDPT was taken by using the Dimaxis Pro
/ Classic soft ware version 3.2.1. and observed for
presence or absence of any radiopacity in the soft
tissue region at the bifurcation of common carotid
artery (CCA). The parameters which measured by
Doppler ultrasound (DUS)include: Hemodynamic
criteria measurements (Velocity parameters
measured by using spectral Doppler include: peak
systolic velocity (PSV)for ICA and CCA, peak
end diastolic velocity (PEDV) for ICA and CCA,
Ratio of PSV for ICA/ PSV for CCA and Ratio of
PEDV for ICA/ PEDV for CCA); Morphological
appearance measurements ( measure the reduction
in lumen diameter and area of ICA and CCA to
calculate the percentages of Linear stenosis and
area stenosis of CCA and ICA); Carotid
ultrasound phenotypes which include: Intimal
media thickness and plaque area measurements for
ICA and CCA in right and left sides. The readings
of the researcher and well trained examiners were
compared and inter and intra examiner calibration
was done through assessing the DDPT image and
DUS readings of 10 subjects from the sample.
RESULTS
The sensitivity and positive predictive value of
the diagnostic performance of DDPT in predicting
atheromal plaque (AP), the DDPT in predicting
FDSS and atheromal plaque detected by DUS in
predicting FDSS was higher when the risk
increase (higher in type II DM group and lowest
in healthy group)(Table 1-3). The present data
analysis demonstrates that there was no statistically
significant differences between control group and
type IIDM group regarding CAC finding on DDPT
51
J Bagh College Dentistry Vol. 23(3), 2011
although the prevalence ratio in groups higher than
control group(table 5). Moreover, calcification
finding shows statistical significant difference
regarding being employed and age (unemployed
had more CAC and over 60 years more CAC (table
4). Statistical significant difference was found
between control group and type IIDM group
regarding carotid atheromal plaque finding on
DUS. Although there was increased risk of
significant stenosis demonstrated by 2out come of
6criteria (FDSS) between groups (prevalence ratio
of FDSS in type IIDM 5 times higher than control
group) the observed increased risk failed to reach
the level of statistically significant (figure 1), also
FDSS shows statistically a significant difference
regarding being employed (employed had less
FDSS than un employed). Statistically found that
there was no significant differences between those
had FDSS or not in study groups regarding mean of
age, acceptable BMI, total cholesterol
concentration, low density lipoprotein
concentration, Atherogenic index, high density
lipoprotein concentration, very low density
lipoprotein(LDL) concentration and triglyceride
concentration, except in the mean of LDL in type II
DM. The prevalence rate of atheroma, FDSS and
CACs were higher in unemployed subjects and
sedentary life style (table 4, 5).
DISSCUSSION
Evaluation of data shows that the sensitivity
and positive predictive value of the diagnostic
performance of DDPT in predicting atheromal
plaque (AP), the DDPT in predicting FDSS and
atheromal plaque detected by DUS in predicting
FDSS was higher when the risk increase (higher
in type IIDM group. The highest prevalence rate
of CAC detected by digital dental panoramic
radiograph DDPT was in type IIDM group
(26.7%) while lowest was in control groups
(20%). All the subjects in the present study were
females not obese, non smoker and from Arabic
origin. The sample was selected in this way to
control for socio-demographic risk factors which
may affect carotid artery stenosis and
calcification. Prevalence in those had history of
type II DM was 40% (statistically there is
significant difference (p=0.02) between this group
and healthy control group) while healthy control
females had 0% prevalence of atheromal plaque.
Similar findings were found to Tyrrell et al (19)
who found that the prevalence of plaque was 25%
among premenopausal women and 54% among
postmenopausal women (P,0.001) but differ
associating with the healthy group. No significant
difference with Almog et al (8) who found that 27
from 778 patients panoramic radiographs had
Oral Diagnosis
The prevalence of cervical
calcifications seen in the region of one or both
carotid bifurcations (Prevalence 3. 5%) in control
healthy group subject prevalence of CAC (20%:
95%CI for prevalence was 0%-40.4%).), but in
type IIDM had higher prevalence rate than Almog
study may be because when the risk factor
increase the prevalence increase.
The present study showed 26.7 % of the type
II DM had CAC, similarly found by the
Friedlander et al (12) whose reported 24 % of the
type II DM subjects had CAC and Al-Suffar and
Uthman (20) findings had higher prevalence
(prevalence 35.7% had CAC). The cause of the
higher prevalence may be because in the present
study less risk factor leads to less prevalence for
CAC).
REFERENCES
1. Hoyert DL, Kochanek KD, Murphy SL .Deaths:
final data for 1997. Natl Vital Stat Rep 1999; 47: 1-104.
2. Williams GR, Jiang JG, Matcher DB, Samsa
GP. Incidence and occurrence of total (first –ever and
recurrent) stroke. Stroke 1999; 30: 2523-8.
3. Liapis CD, Kakisis J D, Kostakis AG. Carotid
Stenosis: Factors Affecting Symptomatology. American
Heart Association 2001;32(12): 2782-6.
4. Beckman J. Carotid Artery Disease. American
Heart Association 2007; 114: 244-7 .
5. Friedlander AH & Friedlander IK. Identification
of stroke prone patients by panoramic dental radiography.
Austral Dent J 1998; 3(1).
6. Bamford J, Sandercock P, Dennis M, Burn J,
Warlow C. Classification and natural history of clinically
identifiable subtypes of cerebral infarction . Lancet 1991;
337: 1521–6.
7. Madden RP, Hodges. JS, Salmon CW, Rindal
DB, Tunio J, Michalowicz B S, and Ahmad M. Utility of
panoramic radiographs in detecting cervical calcified
carotid atheroma. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2006; 6 (48).
8. Almog DM, Horev T, Illig KA, Green RM,
Carter LC. Correlating carotid artery stenosis detected by
panoramic radiography with clinically relevant carotid
artery stenosis determined by duplex ultrasound. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2002; 94(6),
768-73.
9. Kasper DL, Braunwald E, Fauci AS, Hauser SL,
Longo DL, Jameson JL, Harrisons. Principles of Internal
Medicine.16th ed 2005; 2: 1301-2607.
10. Laskaris G. Color atlas of oral diseases .2nd
edition, Thieme Medical Publishers, New York, 1994.
11. Grundy SM. Metabolic complications of
obesity. Endocrine 2000; 3(2), 55-65.
12. Friedlander AH, Altman L. Carotid artery
atheromas in post menopausal women. Their prevalence
on panoramic radiographs and their relationship to
atherogenic risk factor. J Am Dent Assoc 2001;132:130-6.
13. Tamura T, Inui M, Akase MN, Nakamura S,
Okamura K, Tagawa T. Clinico statistical study of carotid
calcification on panoramic radiographs. Oral Diseases
2005; 11: 314.
14. Davies KN, Humphrey PR. Complications of
cerebral angiography in patients with symptomatic carotid
52
J Bagh College Dentistry Vol. 23(3), 2011 The prevalence of cervical

territory ischemia screened by ultrasound. J Neurol
Neurosurg Psychiatry 1993; 56: 967-72.
15. Hankey GJ, Warlow CP, Sellar RJ. Cerebral
angiographic risk in mild cerebrovascular disease. Stroke
1990; 21:209-22.
16. Lewis DA, Brooks SL. Cartoid artery
calcification in a general dental population: a retrospective
study of panoramic radiographs. Gen Dent 1999; 47: 98–
103.
17. Hobson RW II, Weiss DG, Fields WS,
Goldstone J, Moore WS, Towne JB, Wright CB, and the
Veterans Affairs Cooperative Study Group. Efficacy of
carotid endarterectomy for asymptomatic carotid stenosis.
N Engl J Med 1993; 328: 221-7.
18. Allan PL, Dubbins PA, Pozniak MA, McDicken
W N .Clinical Doppler Ultra sound. 2nd edition, Chirchill
Living stone, Edinburah Philadelphia ST, London, 2002.
19. Tyrrell K S, Lassila HC, Meilahn E, Bunker C,
Matthews KA, Kuller LH. Carotid Atherosclerosis in
Premenopausal and Postmenopausal Women and Its
Association With Risk Factors Measured After
Menopause. American Heart Association 1998; 29: 1116-
21.
20. Al-Suffar A BR, Uthman AT. The value of
digital dental panoramic tomography in the identification
of common carotid artery calcification among Iraqi sample
at risk of cerebrovascular accident. A master thesis,
Science in Oral and maxillofacial Radiology, University of
Baghdad, 2007.

Table 1: Assessment of diagnostic performance of CAC observed by DDPT in predicting AP

detected by DUS in the study groups.
Carotid atheromal plaque by Doppler
Negative Positive Total
Healthy group
Panoramic x-ray evidence of CAC Sensitivity= $$$
Negative 26 0 26 Specificity= 87
Positive 4 0 4 False +ve= 13
Total 30 0 30 False -ve= $$$
Accuracy= 87
PPV= 0
NPV= 100
Type II DM
Panoramic x-ray evidence of CAC Sensitivity= 60
Negative 18 4 22 Specificity= 90
Positive 2 6 8 False +ve= 10
Total 20 10 30 False -ve= 40
Accuracy= 80
PPV= 75
NPV= 82

Table 2: Assessment of diagnostic performance of CAC observed by DDPT in predicting FDSS

detected by DUS stratified by study groups
Final diagnosis of significant stenosis
Negative Positive Total
Healthy controls
Panoramic x-ray evidence of CAC Sensitivity= 0
Negative 25 1 26 Specificity= 86.2
Positive 4 0 4 False +ve= 13.8
Total 29 1 30 False -ve= 100
Accuracy= 83.3
PPV= 0
NPV= 96.2
Type II DM
Panoramic x-ray evidence of CAC Sensitivity= 40
Negative 19 3 22 Specificity= 76
Positive 6 2 8 False +ve= 24
Total 25 5 30 False -ve= 60
Accuracy= 70
PPV= 25
NPV= 86.4

Oral Diagnosis 53
J Bagh College Dentistry Vol. 23(3), 2011 The prevalence of cervical

Table 3: Assessment of diagnostic performance of AP in predicting FDSS detected by DUS

stratified by study groups.
Final diagnosis of significant stenosis
Negative Positive Total
Healthy controls
Carotid atheromal plaque by Doppler Sensitivity= 0
Negative 29 1 30 Specificity= 100
Positive 0 0 0 False +ve= 0
Total 29 1 30 False -ve= 100
Accuracy= 96.7
PPV= $$$
NPV= 96.7
Type II DM
Carotid atheromal plaque by Doppler Sensitivity= 40
Negative 17 3 20 Specificity= 68
Positive 8 2 10 False +ve= 32
Total 25 5 30 False -ve= 60
Accuracy= 63.3
PPV= 20
NPV= 85

Table 4:The difference in mean for selected measurements by final diagnosis of SS stratified by
study group.
Healthy controls Type II DM
Final diagnosis of significant
Final diagnosis of significant stenosis
S
Negative Positive P (t-test) Negative Positive P (t-test)
Age in years 0.68[NS] 0.52[NS]
Range (50 - 68) (51 - 51) (50 - 70) (50 - 65)
Mean 53.3 51 59 56.8
SE 1.4 ** 1.92 2.63
N 14 1 10 5

Body mass index

0.75[NS] 0.24[NS]
(BMI) Kg/m2
(21.5 - (23.7 -
Range ( 22.2 – 29 ) ( 26.6 - 26.6)
28.9) 27)
Mean 25.9 26.6 24.7 26.1
SE 0.57 ** 0.69 0.6
N 14 1 10 5

Serum total cholesterol

0.22[NS] 0.11[NS]
conc conc)
(165 - (205 -
Range (169 - 230) (175 - 175)
270) 270)
Mean 199.6 175 199.1 228.8
SE 4.96 ** 10.62 11.53
N 14 1 10 5

Serum LDL conc

0.22[NS] 0.006
(mg/dl)
(135 -
Range (82 - 169) (97 - 97) (84 - 170)
175)
Mean 126 97 118.6 164.4
SE 5.86 ** 8.97 7.43
N 14 1 10 5

Oral Diagnosis 54
J Bagh College Dentistry Vol. 23(3), 2011 The prevalence of cervical

Serum HDL conc

0.54[NS] 0.54[NS]
(mg/dl)
Range (39 - 60) (50 - 50) (40 - 51) (39 - 55)
Mean 46.4 50 45.7 47.2
SE 1.51 ** 0.96 2.84
N 14 1 10 5

Serum VLDL conc

0.92[NS] 0.72[NS]
(mg/dl)
Range (19 - 38) (28 - 28) (19 - 60) (20 - 60)
Mean 27.3 28 33.6 31
SE 1.77 ** 3.63 7.38
N 14 1 10 5
Serum triglycerides
0.94[NS] 0.68[NS]
conc (mg/dl)
(100 - (97 -
Range (94 - 190) (140 - 140)
300) 300)
Mean 137.4 140 169.6 154.4
SE 9.12 ** 17.55 37.11
N 14 1 10 5

Atherogenic index
0.73[NS] 0.43[NS]
(TG/HDL ratio)
(2.2 - (1.9 -
Range (1.6 - 4.2) (2.8 - 2.8)
6.7) 6.7)
Median 2.8 2.8 3.8 2.8
N 14 1 10 5

Table 5: The risk of being positive for selected out comes by study group.
Carotid atheromal plaque by panoramic x-ray evidence of carotid Final diagnosis of significant
Total
Doppler artery calcification stenosis
Study 95% CI P (Fisher's 95% CI for P (Fisher's 95% CI for P (Fisher's
N N% PR N % PR N % PR
group for PR exact) PR exact) PR exact)
Healthy
15 0 0 Reference 3 20 Ref. 1 6.7 Ref.
control
Type II
15 6 40 ** ** 0.02 4 26.7 1.3 (0.3-8.0) 1[NS] 5 33.3 5 (0.7-37.9) 0.17[NS]
DM

Healthy control Type II DM

40
40
33.3
frequency (%)

30 26.7
Relative

20
20
10 6.7
0
0
Carotid atheromal plaque by Doppler panoramic x-ray evidence of calcified Final diagnosis of significant stenosis
atheroma plaque of carotid artery

Figure 1: The relative frequency (prevalence rate) of 3 selected findings (carotid AP by DUS,
CAC detected by DDPT and FDSS detected by DUS) between the study groups

Oral Diagnosis 55
 J Bagh College Dentistry Vol. 23(3), 2011 Assessment of serum

Assessment of serum and salivary oxidative stress

biomarkers with 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; measurement of oxidative stress in saliva has to be discovered,
evaluated and measured in autistics to be used as a potential diagnostic aid since saliva is an ultra-filtrate of serum
and meet the demand for inexpensive, noninvasive and accessible diagnostic methodology.
Materials and methods: Oral health status: DMFT/dmft and gingival indices as well Serum and salivary
Malondialdehyde (MDA) levels , glutathione (GSH), superoxide dismutase (SOD) and uric acid (UA) 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, with
significant abnormalities of the oxidative stress biomarkers.
Conclusion: Saliva can be used as adjunctive diagnostic aid for measurement of the oxidative stress in autism. Serum
GSH and uric acid then serum and salivary Malonyldialdehyde followed by salivary glutathione and serum
superoxide dismutase are the most powerful predictors of autism spectrum disorder respectively.
Key words: Autism spectrum disorder; Oxidative stress; Oral health status. (J Bagh Coll Dentistry 2011;23(3): 56-60).

INTRODUCTION The brain is highly vulnerable to oxidative

Autism spectrum disorders (ASDs) are
prevalent neurodevelopmental disorders that
affect an estimated 6 per 1,000; with male to
female ratio averages 4.3:1, which means that
boys are at higher risk for ASD than girls
(1)
.Characterized by severe impairments in
socialization, communicat- ion and behavior.
Children diagnosed with an ASD may display a
range of problem behaviors such as hyperactivity,
poor attention, aggression and self-injury. In
addition, to unusual responds to sensory stimuli
such as hypersensitivities to light or certain
sounds, colors, smells or touch and have a high
threshold for pain(2). Finally, common co-
morbidity conditions often associated with ASDs
include gastrointestinal and autoimmune disease
(3)
. neurodevelopmental disorders such as autism (5).
Investigators suggested that ASDs may result
from an interaction between genetic, environme-
ntal and immunological factors, with oxidative
stress as a mechanism linking these risk factors (4).
________________________________________
(1) M.Sc. Oral medicine, Department of Oral Diagnosis, College
of Dentistry, Baghdad University
(2) Professor, Department of Oral Diagnosis , College of
Dentistry, Baghdad University
stress due to its limited antioxidant capacity,
higher energy requirement, and higher amounts of
lipids and iron. The brain makes up about 2% of
body mass but consumes 20% of metabolic
oxygen. Due to the lack of glutathione-producing
capacity by neurons, the brain has a limited
capacity to detoxify ROS. Therefore, neurons are
the first cells to be affected by the increase in
ROS and shortage of antioxidants and, as a result,
are most susceptible to oxidative stress. Children
are more vulnerable than adults to oxidative stress
because of their naturally low glutathione levels
from conception through infancy. Taken together,
these studies suggest that the brain is highly
vulnerable to oxidative stress, particularly during
the early part of development that may result in
Under normal conditions, dynamic
equilibrium exists between the production of
reactive oxygen species (ROS) and the
antioxidant capacity of the cell. ROS includes
superoxide (O2•−), hydroxyl, peroxyl and nitric
oxide (NO) free radicals (6). The two main roles of
cellular antioxidant defence mechanisms are to
prevent the generation of free radicals and to
inactivate them after generation. This system
includes enzymatic and non-enzymatic processes.
Superoxide dismutase (SOD), glutathione
peroxidase (GSH-Px), hydrogen peroxidase and
catalase (CAT) are the antioxidant enzymes which

Oral Diagnosis 56
J Bagh College Dentistry Vol. 23(3), 2011
block the initiation of free radical chain reactions.
Glutathione (GSH), alpha-tocopherol (vitamin E),
ascorbic acid (vitamin C) and urate are the main
non-enzymatic antioxidant molecules (7).
MATERIALS AND METHODS
Sixty individuals from Central Pediatric
Teaching Hospital in Al-Iskan were enrolled in
this study. They were categorized into two
groups:
Autistic group: Composed of 31 children (29
males and 2 females) who were diagnosed as
autistic children, their age ranges between 2-13
years. Because the female sample very small, it
was excluded from the current study.
Healthy control group: It was composed of 29 age
and gender matched male children.
All individuals were evaluated by full medical
history and clinical examination to exclude any
other systemic disease that may affect the
parameters examined in this study. Oral and
periodontal examination was done for each
individual and any child with symptoms and signs
of any active oral inflammation and advanced
periodontitis were excluded.
All parents were supplied with informed
consent and the purposes of the study were
explained to them. All the children subjected to
extra-oral examination for any scars or trauma to
the head, neck, hands and fingers; tacking
medical, family history and previous dental
history.Intra-Oral assessment of caries experience
through the application of decayed, missing and
filled teeth Index (DMFT) and (dmft) for
permanent and primary teeth respectively; and
assessment of gingival health status through
gingival index (8).
Laboratory assessment: Blood and saliva
samples were taken from autistics and control. 5
ml. of blood sample was taken from each
individual, left to clot then the serum which was
obtained by centrifugation at 3000 rpm for 10
minutes, transferred immediately into another
tube and frozen at (-20 0c) for subsequent
analysis. For salivary samples each child was
asked to sit down and relax-as much as possible-
and asked to chew apiece of Arabic gum for one
minute before all the saliva was removed by
expectoration; chewing was then continued for ten
minutes with the same piece of gum and the
collection of saliva by spitting was done during
this time. The collected saliva was centrifuged at
1000 rpm for 10 minutes; this done after 1 hour
after collection to eliminate debris and cellular
matter. The centrifuged supernatants stored frozen
at (-200c) in polyethylene tube until assayed.
Oral Diagnosis
Assessment of serum
Serum and salivary levels were assessed for
MDA using thiobarbituric acid (TBA) method (9),
Uric acid by using commercial kit (BioMerieux,
France). GSH levels according to the method
described by Burtis and Ashwood(10), SOD
activity were also assessed using The assay
method involves the inhibition of autooxidation of
adrenaline to adrenochrome by SOD (11).
All data were statistically analyzed using
SPSS version 13 (Statistical Package for Social
Sciences). Non-normally distributed quantitative
variables (serum and salivary GSH in addition to
DMFT\dmf score) are described by median and
interquartile range. The remaining quantitative
variables (age, serum and salivary uric acid,
serum and salivary MDA, serum and salivary
SOD and gingival index) were normally
distributed and thus conveniently described by
mean ± standard deviation. Correlation
assessment was performed using the Spearman
correlation analysis. The ROC analysis was used
to rank the quantitative parameters from those
with highest difference between Autism cases and
healthy controls to lowest difference. This is done
by ranking the ROC area of different parameters.
Statistical significance was defined as p< 0.05.
RESULTS
The mean age for autistic children was about
5.9±3.4 years. Autistics and their controls showed
homogeneity and there were no significant
difference between the two groups.
Extra-Oral Examination: out of 29 autistics only 2
(6.9%) showed signs of trauma due to self injury
habit. Parents' responses to the questionnaire
regarding dental visits indicated that 28 (96.6%)
of autistic children never visited dental clinic and
had a negative history of treatment and follow up.
Intra – Oral Examination: The caries severity of
children in the ASD group was statistically
significant lower than that in the unaffected group
for dmft (p = 0.013) but insignificant for DMFT
(p = 0.73). Regarding caries prevalence, a total of
15 (51.7%) children in the ASD group had a
positive caries free history (DMFT and dmft =0),
compared with 9 (31%) children in healthy
control group.
According to the criteria, 96,6% of autistic
children had mild gingivitis with mean value
(0.55 ± 0.35) obviously lower in comparison to
healthy controls (0.75 ± 0.48), but the difference
failed to reach the level of statistical significance
(p=0.08).
Biochemical Findings: It was observed that the
study subjects with ASD had significantly
increased serum and salivary MDA and serum UA
(p< 0.001). By contrast, the study subjects with an
57
J Bagh College Dentistry Vol. 23(3), 2011
ASD had significantly decreased levels of serum
and salivary GSH (p< 0.001) and serum SOD (p =
0.004). No overall significant differences were
observed for the salivary UA and SOD among
study subjects with an ASD and their controls.
Tables 1 and 2 summarize an assessment of
biomarkers of oxidative stress among the study
subjects with ASD in comparison to the controls.
Table 3 showing the tested variables ordered
according to their significance in separating
between autistics and healthy controls (ROC test).
DISCUSSION
Boys are at higher risk for ASD than girls and
this agreed with all other studies around the world
(1,3)
. As part of the multiple unknown develop-
mental abnormalities, children diagnosed with
autism practice self injurious behavior (SIB) at
some stage in their lives. In the present study
results of the extra oral assessment, types of
habits, trauma and injuries revealed that out of the
29 examined children, only 2 (6.9 %) practice this
behavior, and this result was in good agreement
with many other studies (12,13). Heritability
contributes about 90% of the risk of a child
developing autism, and this support the findings
in the present study in which 21 (72.4 %) of
autistic children have a positive family history of
neuropsychiatric illness like schizophrenia, Alzhe-
imer’s disease, mental disorder and depression (14).
In the present study 28 children (96.6%) had
never visited dental clinic or received dental
treatment and follow up and this could be
explained by the fact that people with ASD
incapable of cooperating in the dental setting
owing to their impaired social interaction and
communication skills. This result was in good
agreement with many studies (15-18).
The current study revealed that caries severity
(but failed to reach statistical significant level) in
autistics were lower than in unaffected children
with autism, because of their ritualistic behavior
which characterized by unvarying pattern of daily
activities, such as an unchanging menu so they are
more regular in their behavior at meals than are
unaffected children. Therefore, a lower frequency
of snacking between meals and lower intake of
carbohydrates could have contributed to the lower
caries rate observed and this finding agreed with
several studies (13,19).While disagreed with others
who reported higher scores in autistic groups
(20,21)
. Caries prevalence lower in autistic children
participating in the present study and this result
were in good agreement with many previous
studies (13, 20).
Gingival status of the autistic children in the
present study showed that (96,6%) of the children
Oral Diagnosis
Assessment of serum
had generalized mild gingivitis, which it was in
good agreement with many previous studies (20,21).
While Ozdemir-Ozenen and Sandalli, 2007 (22), in
their study reported that the gingival index records
of the children with autism was found to be
significantly higher than the healthy children.
Oxidative stress and antioxidant activity is
now well known to be the mechanism that links
genetics, environment, and immunity as causative
factors for autism (4). In the present study, aim was
directed to assess and measure the oxidative stress
marker (MDA) and the antioxidants (UA, GSH
and SOD) in serum and saliva of autistics; and
moreover any oral manifestations associated with
ASD, which could be used for the early diagnosis
and intervention with autism. Although there is no
known cure, but early behavioral or cognitive
intervention can help autistic children gain self-
care, social, and communication skills.
Up to our knowledge, this study is the first of
its kind that evaluate the usefulness of saliva as
diagnostic/monitoring aid through measuring the
oxidative stress and status of the protective
antioxidant under condition of stress due to autism
in a sample of Iraqi autistics.
Malondialdehyde (MDA) levels were
assessed in serum and saliva of all participants.
Serum MDA level was significantly higher in
autistics compared to normal controls which could
be due to increased generation of reactive oxygen
species (ROS) due to the excessive oxidative
damage generated in these children, and this
agreed with many studies (23,24,25). Salivary MDA
levels are directly affected by systemic oxidative
stress, since they were also significantly elevated
in saliva of autistics; but there was no reported
previous study for compression. These levels
making MDA highly significant accurate
parameter in prediction of ASD as they ranked
second in importance (ROC area around 0.8) for
both serum and saliva (table 3).
Uric acid is the final product of purine
metabolism in humans. During purine metabolism
molecular oxygen was used as electron acceptor
and generation of superoxide anion and other
reactive oxygen products occur. Uric acid may be
a marker of oxidative stress, and may have a
potential therapeutic role as an antioxidant. On the
other hand, like other strong reducing substances
can also act as a prooxidant, particularly at
elevated levels. Thus, it is unclear whether
elevated levels of uric acid in diseases associated
with oxidative stress are a protective response or a
primary cause (26,27).
The present study found that the mean level of
serum UA was significantly increased in autistics
when compared with that of healthy controls and
58
J Bagh College Dentistry Vol. 23(3), 2011
this was in agreement with previous study of Page
& Coleman, 2000 (28) which reported that urate
excretion is elevated 2-3-fold in hyperuricosuric
subclass of autistic patients compared to normal
controls. But other studies reported that
hyperuricosuric autistic subject showed
improvements in speech, attention, and social
interaction on a low purine diet; these findings
might suggest that uric acid itself may be
responsible for autistic and/or neurological
symptoms (29,30).
Salivary UA on the other hand, showed
insignificant increase in autistics when compared
with that of healthy controls. But there were no
reported previous studies on level of UA in saliva
of autistics to compare our results with.
In consistence with the above findings,
Pearson correlation coefficient was applied in this
study between parameters revealed that serum UA
had a highly significant moderately strong
positive (direct) correlation with serum MDA (r =
0.483) which is widely utilized as a marker of
lipid peroxidation in states of elevated oxidative
stress. And according to results of ROC test serum
UA was significantly accurate, (parameter number
one) in this study in prediction of Autism
spectrum disorder as shown in table 3.
Glutathione (GSH) high concentration and its
central role in maintaining the cell's redox state,
therefore it is one of the most important cellular
antioxidants. In the present study, serum GSH
level of autistics was significantly depleted in
comparison to that of healthy controls, and this
could be correlated to the impaired defense
mechanism against damage by ROS in autism
which supported through considering the previous
reports (3,4,23). Increased lipid peroxidation
together with the observed depletion of GSH
supports the oxidative stress hypothesis in ASD.
Salivary GSH level in this study was shown to be
significantly decreased in comparison to healthy
controls but there was no previous reported
studies to compare with. The ROC test results of
this study revealed the diagnostic value of serum
GSH, as the most accurate parameter in prediction
of ASD since it ranked number one (ROC area
around 0.9). Salivary GSH was also highly
significant accurate in prediction of ASD as
ranked third in order of importance (ROC area
around 0.7) in this study as shown in table 3.
Superoxide dismutase (SOD) is a potent
protective enzyme that can selectively scavenge
superoxide anion by catalyzing its dismutation to
H2O2 and oxygen (O2). Several studies proposed
that altered activities of antioxidant system might
have a pathophysiological role in autism (31).
Oral Diagnosis
Assessment of serum
Results obtained from current study
demonstrate a significant reduced level of SOD in
serum of autistic children, which confirmed the
remarkable depletion SOD in autistic samples,
since the brain contains high levels of oxidizable
lipids that must be protected by antioxidants. This
could find a support through considering previous
works (7), but disagreed with many others
(3,23)
.Salivary SOD activity was insignificantly
lower in autistics compared to control, but there
was no previous study on SOD level in saliva of
autistics to compare with. The results of ROC test
in this study revealed that serum SOD was
significantly accurate in prediction of ASD, since
ranked as parameter number three in order of
importance in this study (table 3).
REFERENCES
1. Newschaffer CJ, Croen LA, Daniels J et al. the
epidemiology of autism spectrum disorders. Annu
Rev Public Health 2007; 28:235–58.
2. Austin D. An epidemiological analysis of the ‘autism
as mercury poisoning’ hypothesis. International J
Risk and Safety in Medicine 2008; 20:135-42.
3. Geier, Kern, Geier. A prospective study of oxidative
stress biomarkers in autistic disorders. Electronic J
Applied Psychology 2009; 5(1): 2-10.
4. James SJ, Melnyk S, Jernigan S, Cleves MA, Halsted
CH, Wong DH, Cutler P, Bock K, Boris M,
Bradstreet JJ, Bake SM, Gaylor DW. Metabolic
endophenotype and related genotypes are associated
with oxidative stress in children with autism.
American J Medical Genetics, Part B:
Neuropsychiatric Genetics 2006; 141: 947-56.
5. Abha Chauhan, Ved Chauhan. Oxidative stress in
autism. J Pathophysiology 2006; 13: 171–81.
6. Granot E, Kohen R. Oxidative stress in childhood - in
health and disease states. Clin. Nutr 2004;23: 3–11.
7. Yorbik O, Sayal A, Akay C, Akbiyik DI, Sohmen T.
Investigation of antioxidant enzymes in children with
autistic disorder.Prostaglandins Leukot. Essent. Fatty
Acids 2002; 67: 341–343.
8. Silness J, Löe H. Periodontal disease in pregnancy II
correlation between oral hygiene and periodontal
condition. ACTA Odontol Scand 1963; 22:121-135.
9. Shah SV, Walker PD. Evidence suggesting a role for
hydroxyl radical in glycerol induced acute renal
failure. Am J Physiol 255(Renal, fluid, electrolyte
physiol) 1989; 24: 3: 438–43.
10. Ashwood P, Van de Water J. Is autism an
autoimmune disease? Autoimmunity Rev 2004; 3:
557–62.
11. Misra Hara P, Irwin Fridovich. The Role of
Superoxide Anion in the Autoxidation of Epinephrine
and a Simple Assay for Superoxide Dismutase. The J
Biological Chemistry 1972; 247:10: 25:3170-5.
12. Dominick KC, Davis NO, Lainhart J, Tager-Flusberg
H, Folstein S. Atypical behaviors in children with
autism and children with a history of language
impairment. Res Dev Disabil 2007; 28(2):145–62.
13. Cheen Y, Loo, Richard M, Graham, Christopher V,
Hughes. The Caries Experience and Behavior of
Dental Patients with Autism Spectrum Disorder. J
Am Dent Assoc 2008; 139: 11: 1518-24.
59
J Bagh College Dentistry Vol. 23(3), 2011 Assessment of serum

14. Freitag CM. The genetics of autistic disorders and its
clinical relevance: a review of the literature. Mol
Psychiatry 2007; 12(1):2–22.
15. Barbaresi WJ, Katusic SK, Voigt RG. Autism: a
review of the state of the science for pediatric
primary health care clinicians. Arch Pediatr Adolesc
Med 2006; 160(11):1167–75.
16. Friedlander AH, Yagiela JA, Paterno VI, Mahler ME.
The neuropathology, medical management and dental
implications of autism. J Am Dent Assoc 2006;
137(11):1517–27.
17. Marshall J, Sheller B, Williams BJ, Mancl L, Cowan
C. Cooperation predictors for dental patients with
autism. Pediatr Dent 2007; 29 (5): 369–76.
18. Pilebro C, Backman B. Teaching oral hygiene to
children with autism. Int J Paediatr Dent 2005; 15
(1):1–9.
19. Lam KSL, Aman MG. The Repetitive Behavior
Scale-Revised: independent validation in individuals
with autism spectrum disorders. J Autism Dev Disord
2007; 37(5):855–66.
20. Ebtissam Zakaria Murshid. Oral health status, dental
needs, habits and behavioral attitude towards dental
treatment of a group of autistic children in Riyadh,
Saudi Arabia; Saudi Dent J 2005; 17: 3: Sept–Dec.
21. DeMattei R, Cuvo A, Maurizio S. Oral assessment of
children with an autism spectrum disorder. J Dent
Hygiene 2007; 81:,3.
22. Özdemir Özenen D, Çıldır ŞK, Sandallı N. The oral
health status of children with visual impairment. 12th
Congress of the BaSS, İstanbul, Türkiye; 2007;.12-4.
23. Al-Gadani Y, El-Ansary A., Attas O, Al-Ayadhi L.
Metabolic biomarkers related to oxidative stress and
antioxidant status in Saudi autistic children. Clinical
Biochemistry 2009; 42; 1032–40.
24. Sen CK, Khanna N, Rin CC, Roy S. Tocotrienols.
The emerging face of natural vitamin E. Vitam Horm
2007; 76:203–61.
25. Sofia Tsaluchidu, Massimo Cocchi, Lucio Tonello,
Basant K Puri. Fatty acids and oxidative stress in
psychiatric disorders. BMC Psychiatry 2008; 8
(Suppl 1):S5.
26. Glantzounis GK, Tsimoyiannis EC, Kappas AM,
Galaris DA "Uric acid and oxidative stress". Current
Pharmaceutical Design 2005; 11 (32): 4145–51.
27. Proctor PH. Uric acid: neuroprotective or neurotoxic?
Stroke 2008; 39 (5): 88; 89.
28. Page T, Coleman M0 Purine metabolism
abnormalities in a hyperuricosuric subclass of autism.
Biochimica et Biophysica Acta 2000; 1500; 291-6.
29. Coleman M. Autism: non-drug biological treatments,
in: C. Gillberg (Ed.), Diagnosis and Treatment of
Autism, Plenum Press 1989; New York: 219-235.
30. Hooft C, Van Nevel C, De Schaepdryver AF.
Hyperuricosuric encephalopathy without
hyperuricemia. Arch Dis Child 1968; 43: 734-7.
31. Johnson S. Micronutrient accumulation and depletion
in schizophrenia, epilepsy, autism and Parkinson’s
disease? Med Hypotheses 2001; 56:641–5.

Table 1: Mean±SD for tested parameters

Markers Cases Controls p
Serum UA (µmol/L) 296.2 ± 28.2 164.3 ±74.3 <0.001
Salivary UA (µmol/L) 89.2 ± 29.5 83.9 ±88.1 0.78 [NS]
Serum MDA (µmol/L) 13.6 ± 4.5 6.6 ±4.8 <0.001
salivary MDA (µmol/L) 11.6 ± 3.3 5.7 ±3.9 <0.001
Serum SOD (unit/L) 0.059 ±0.085 1.231 ±0.302 0.004
SalivarySOD (unit/L) 1.392 ± 0.21 1.561±0.358 0.05 [NS]

Table 2: Median level for selected parameters

Markers Cases Controls p
Serum GSH (µmol/L) 147.2 1398.4 <0.001
Salivary GSH (µmol/L) 36.8 588.8 <0.001

Table 3: ROC analysis for tested parameters

parameters Area under the curve
P
Salivary MDA 0.876 <0.001
Serum MDA 0.851 <0.001
Salivary GSH 0.788 <0.001
Serum SOD 0.734 0.002
Salivary SOD 0.683 0.025
Dmf 0.669 0.027
Salivary UA 0.652 0.06[NS]
Gingival index 0.622 0.11[NS]
DMF 0.521 0.79[NS]

Oral Diagnosis 60
J Bagh College Dentistry Vol. 23(3), 2011 Histological study of the

Histological study of the effect of eucalyptol oil vapours on

the development of the palate and tooth germ
(experimental study on rats)
Muhanad T. Jehad , B.D.S., M.Sc. (1)
Athraa Y. Al- Hijazi , B.D.S.,M.Sc., Ph.D. (2)

ABSTRACT
Background: Eucalyptol is a natural organic compound. The aim of this study was to evaluate the effect of the
eucalyptol oil vapour on the palate and tooth germ development of rats embryos for the periods of (16th day ,18th day
intrauterine life and one day old rats) histologically and histomorphometrically.
Materials and Methods: In this study thirty pregnant albino Wistar female rats(2-3 months of age, 200-250 gm of weight)
were divided into two groups: Control group not subjected to the synthetic eucalyptol oil inhalation vapour and
experimental group subjected to the synthetic eucalyptol oil inhalation vapour. The embryos at 16,18 day of intrauterine
life and one day old were histologically studied for the development of palate and molar tooth germ development.
Results: The results demonstrated a retardation of the palate and tooth germ development of 16th and 18 th intrauterine
life embryos of experimental groups in comparison to control. Immature enamel , wide predentin and interglobular
dentin were detected in the tooth germ of embryo (one day old) from pregnant rats exposed to the eucalyptol oil
vapour.
Conclusions : Eucalyptol oil vapour can affect on the palate(Failure of fusion of palatine shelves) and tooth germ
development (mineralization and maturation process of dentin and enamel respectively showing immature enamel
and interglobular dentin with wide predentin ) .
Key words: Eucalyptol oil, Wistar rats, palate , molar tooth germ, palatine shelves. (J Bagh Coll Dentistry 2011;23(3): 61-
66).

INTRODUCTION Other reports showed that prolonged

Eucalyptol is widely distributed in plants.
The main food sources are eucalyptus oil (up to
80% eucalyptol), the herbs and spices mugwort,
sweet basil, rosemary, sage, cardamom and their
essential oils. Eucalyptol is a monocyclic terpene
with an ether bridge between carbon 1 and 8.
Eucalyptol, 1, 8 cineole, is an essential oil, present
in large amounts in a variety of plants which is
frequently used in the manufacture of cosmetics to
increase percutaneous penetration of drugs, as a
nasal decongestant and anticough agent, in
aromatherapy, and in dentistry. Eucalyptol has
been used to treat bronchitis, sinusitis, chronic
rhinitis and for the treatment of asthma. These
actions seem to be related an anti inflammatory
action inhibiting the production of tumor necrosis
factor alpha (1).
Gastric protection preventing ethanol-
induced injury was reported in rats. This
compound also enhances blood circulation, leading
to skin hyperemia after local application.
(1) MSc student, dep. of Oral diagnosis (oral histology and
biology), College of Dentistry , University of Baghdad.
(2) Professor, Assistant Dean of the College of Dentistry,
University of Baghdad.
exposure to eucalyptol (inhalation); increases
cerebral blood flow correlated with eucalyptol
concentration in blood, suggesting a vasodilator
action. Cardiovascular effects were also recently
reported (2) showed that eucalyptol reduced heart
rate by a parasympathetic-dependent action and
induced hypotension by a direct vasodilation
relaxation. Eucalyptol is metabolized to 2-exo-
hydroxy-1,8 cineole by microsomes from human
and rat liver, but it is not clear whether this
substance can be metabolized by humans, in vivo .
Eucalyptol diffuses faster by inhalation than by
oral administration or through the skin. Its
presence can be detected in blood 5 min after
inhalation, with maximal concentration being
reached within18 min .Non-fatal symptoms were
observed in children following nasal
administration of eucalyptol. Effects included
mucous membrane irritation, tachycardia, dyspnea,
nausea, vomiting, muscle weakness, somnolence,
and coma (3). The oil is found in numerous over-
the-counter cough and cold lozenges as well as in
inhalation vapors or topical ointments.
The oil has antifungal and antibacterial
activity against Bacillus subtilis, Staphylococcus
aureus, and Escherichia coli. Eucalyptus oil is
generally nonirritating, nonsensitizing and

Oral Diagnosis 61
J Bagh College Dentistry Vol. 23(3), 2011
nonphototoxic to the skin. Essential oils are widely
used in cough drops . It increases cardiac action;
an emulsion made by shaking up equal parts of the
oil and powdered gum-arabic with water has been
used as a urethral injection, in croup and
spasmodic throat troubles, the oil may be freely
applied externally, the oil is an ingredient of
catheder oil, used for sterilizing and lubricating
urethral catheters (4 ).The industrial oils containing
terpenes, which are used for flotation purposes in
mining operations. The cosmetic industry uses it as
a fragrance component in soaps, detergents, air
fresheners, bath oils, and perfumes. Eucalyptus
hybrid 'Mysore' is a promising source of pinenes,
which are used in synthetic camphor, pine oil,
terpineol, and in dry cleaning fluids, solvents, and
cheap deodorants (5).
MATERIALS AND METHODS
In this study thirty pregnant albino Wistar
female rats(2-3 months of age, 200-250 gm of
weight) were divided into two groups: Control
group: consisted of 15 pregnant rats, not subjected
to the synthetic eucalyptol oil inhalation vapour
but subjected to boiling water inhalation vapour ;
and experimental group: consisted of 15 pregnant
rats, subjected to the synthetic eucalyptol oil
inhalation vapour(120 µl eucalyptol oil in 250 ml
boiling water) ; for half an hour from day zero of
gestation and for one week . The embryos of rat
were obtained at different period of gestation. The
embryos at 16,18 day of intrauterine life and one
day old were histologically studied for the
development of palate and molar tooth germ,
sagittal sections through the head of the embryos
which were separated from the body . The
specimens were prepared for processing and
staining with haematoxylin and eosin, and
examined under light microscope.
RESULTS
This study demonstrated a significant
reduction in the weight measurement of embryos at
18 th day intrauterine life of experimental group as
shown in (figure 1) in comparison to control
.While a non significant value as illustrated in
weight of embryos at 16th day intrauterine life and
Oral Diagnosis
Histological study of the
in one day old of experimental in comparison to
control. Rat embryo of 16 days intrauterine life
subjected to the vapour synthetic eucalyptol oil as
shown in (figure 3): showed high-elevated tongue
filled the space of the oral cavity and lie in
between palatal shelves. Palatal shelves seemed to
grow horizontally not fused yet. Nasal septum was
detected away from the palatal shelves. Sagittal
sections through the upper and lower jaws showed
thickened of the oral epithelium. Rat embryo of 18
days intrauterine life subjected to the vapour
synthetic eucalyptol oil as shown in (figure 6)
:showed horseshoe –shaped dental arch with
presences of primodium of tooth germ along the
arch. High magnification power view showed tooth
germ in bud stage.
Rat embryo of one day old subjected to the
vapour synthetic eucalyptol oil showed apposition
of hard tissue. Polarized ameloblast showed tomes’
process facing the developing enamel while
odontoblast cells showed to be not well be
polarized and not well be arranged faced the
developing dentin as shown in (figures 4,5) . The
predentin showed to be wide , calcospherite can be
detected.
1,4
1,249
1,2
1
0,74
0,8
M ean
0,6
0,4
0,2
0
18 day control/18day
18 day Control /18
Figure 1 : Eucalyptol effect on the weight of 18 th
day rat embryo
62
J Bagh College Dentistry Vol. 23(3), 2011 Histological study of the

Figure 2: A view for rat embryo of one day old (control group)
showing tooth germ in advance bell stage, dentine (D), odontoblast
(OD), enamel (E), predentin (PD) , pulp (P) ,cervical loop (CL)
(HαE ×100).

Figure 3: Microphotograph view for rat embryo of 16-days intrauterine

life with synthetic eucalyptol oil vapour , showing palatine shelf (PS),
nasal septum (NS), tongue (T) high elevated (HαE ×25).

Figure 4: Tooth germ of upper jaw of subjected rat embryo of one

day old with synthetic eucalyptol oil vapour , showing dental
papilla (DP),dentine (D) and enamel (E).(HαE ×25).

Oral Diagnosis 63
J Bagh College Dentistry Vol. 23(3), 2011
DISCUSSION
The present study is concerned with tooth
development and its relation to the synthetic
eucalyptol oil vapour exposure, extending from
early sign of developmental stages to the
completion of coronal tooth formation including
all the consequences of dentinogenesis and
amelogenesis, therefore the design of research was
selected:
First: pregnant rat from day zero (time of
gestation) to expose it to the synthetic eucalyptol
oil vapour.
Second: To follow up the effect of the synthetic
eucalyptol oil vapour on embryo and specifically
to the tooth germ of embryo and its related
structure coincide with the age of embryo.
The research studied rat embryo at age 16 day
intrauterine life as it illustrated normal tooth
development at bud stage regulated by inductive
interactions between cells of the ectodermal lining
of the first branchial arch and the underlying
mesenchyme. Development begins with a
thickening of the oral epithelium, which grows into
the mesenchyme forming a bud and inducing the
condensation of mesenchymal cells.
At 18 day intrauterine life, morphogenesis
proceeds as the epithelial cells proliferate and form
Oral Diagnosis
Histological study of the
Figure 5: High magnification view showed odontoblast
cells (OD) , dentin , (D), enamel (E),ameloblast cells
(AB),with Tomes’ process(TP) for subjected rat embryo
of one day old with synthetic eucalyptol oil vapour .
(HαE ×200).
Figure 6: Low power magnification view for subjected
rat embryo of 18-days intrauterine life to synthetic
eucalyptol oil vapour showing dental lamina (DL) cover
the ridge (upper), tongue (T), (HαE ×25).
the enamel organ surrounding the mesenchymal
dental papilla and the tooth germ in bell stage.
The late bell stage concerned in the rat embryo of
one day old (new born ) showing tooth specific
cells formed from dental papilla nearest to the
epithelium differentiated cells into odontoblast and
ameloblast, respectively (6 ) . In the present study
the cap stage has been shown to be a particularly
vulnerable stage of the tooth development .As
there is a little differences in the time of the tooth
development for the first and second molars of the
rat and to be precise in the detecting of any
variation which illustrates the effect of eucalyptol
we selected first and second molars of the rat only
and in addition it is more easily to be approach for
histological findings.
In all literature studied for eucalyptol effect or its
related family on tooth development or other parts
of the body (liver, lung .....etc ).Using of it either
orally (oral intubation) (7), capsules (8)
,intraperitoneal injection (9) , intravenous dose (
10 ) ( 11 )
and intravenous injection for in vivo study
and for in vitro study as addition of certain dose to
the incubated media which differs from our
methodology in using eucalyptol oil as a vapour in
pregnant rat .The projection of the idea related to
the use of eucalyptol oil vapour in our country for
treatment of nasal blockage .Therefore no
64
J Bagh College Dentistry Vol. 23(3), 2011
research was found to be close to the present work
and no work to illustrate the effect of the use of
eucalyptol oil vapour by pregnant women on their
embryos.
At first time the pregnant rat subjected to 200 µ l
of eucalyptol oil in 250 ml boiling water(vapour)
for half an hour exposure showed abortion after 7-
10 days, others died and because of it is an
experimental research we reduced the vapour dose
into 120 µl microliter of eucalyptol oil in 250 ml
boiling water (vapour) for half an hour duration .
The results showed reduction in the weight of the
embryos at 18 th day intrauterine life in
comparison to the control ones and it is in
agreement with (12) who used related family of the
eucalyptol (2,3,7,8-tetrachlorodibenzo-para-
dioxin) for adult male rats and they found a
reduction in the weight with significant difference
in skull size of the experimental rat in comparison
to the control one .
Histological Findings
The results of the present study showed
retardation in the palate and tooth development for
experimental group in comparison to the control .It
illustrates thickening of the oral epithelium only
without detection of tooth germ buds at age 16 day
intrauterine life and palatal shelves showed failure
of fusion .It supposed that there is a retardation in
the metabolic activity if we link with the clinical
observation which include reduction in the body
weight and the eucalyptol oil as a chemical agent is
ubiquitous environmental contaminants that has
many adverse biological effects .
Their persistence and accumulation in tissue and in
the food chain may result in metabolic
disturbances and act as a developmental toxicant
(13)
.The detailed mechanisms underlying the
spectrum of toxic responses and metabolic
retardation elicited by the eucalyptol oil are poorly
understood and need for more researches . At 18
day intrauterine life the experimental embryos rat
showed tooth germs in bud stage, transited bud to
cap stage rather than bell stage which detected in
control groups. Retardation in the tooth
development at that time suggested arrest of cell
differentiation and may be related to poor
interaction between mesenchymal cells and
epithelial cells and to biological signals that aids in
cell differentiation.
Tooth development is genetically strictly
controlled but susceptible to environmental
disturbances . Among chemicals that have been
found to interfere with tooth development in
Oral Diagnosis
Histological study of the
clinical and experimental studies are
environmental toxicants such as dioxin and
nonhalogenated polycyclic aromatic hydrocarbons
as well as fluoride and certain drugs .The effects
are not only depend upon the chemical concerned
and the dose concentration but also the stage of the
tooth development at the time of exposure (14,15)
At one day old rat control group showed well
apposition of hard tissue enamel and dentin
including maturation and mineralization process
respectively. Because of the dental hard tissues are
not replaced once they have been formed. Tooth
seemed to be an informative organ model for
studying abnormal mineralized tissue formation
and eucalyptol vapour has been shown to have
adverse effects on odontoblast and ameloblast.
Morphogenesis of ameloblast of experimental
group like control once they were polarized,
elongated ,showing Tomes’ process but enamel
showed a defect in a maturation and could be
explained that eucalyptol effect ameloblast
function and their differentiated stage specifically
the maturative stage .For odontoblast cell of
experimental group showed morphological change
with functional disturbances in comparison to the
control . Wide predentin and its border to be
mineralized dentin was markedly globular. The
results are in line with (13) findings who showed
that lactational exposure of rats to 2,3,7,8
tetrachlorodibenzo-p-dioxin interfere with enamel
maturation and retards dentin mineralization and
they suggested that chemical agent arrests the
degradation and matrix proteins or removal of
enamel . While for dentin, they found wide
predentin and related that to failure of
implementation of mineralization or to failure of
the conversion of predentin to dentin which
involves not only cellular activities but also to
structural and compositional changes in the
collagenous matrix (16) . The line of this study is
concerning the effects of eucalyptol vapour on the
embryonic tooth germ showed to involve the
inductive interactions between epithelial and
mesenchymal cells and extend to the
dentinogenesis and amelogenesis process.
REFERENCES
1. Juergens U. Anti-inflammatory activity of 1.8-cineol
(eucalyptol) in bronchial asthma: a double-blind
placebo-controlled trial. Respiratory Medicine 2003;
97 (3) :250 - 256.
2. Sfara V, Zerba EN, Alzogaray RA. "Fumigant
Insecticidal Activity and Repellent Effect of Five
Essential Oils and Seven Monoterpenes on First-Instar
65
J Bagh College Dentistry Vol. 23(3), 2011 Histological study of the

Nymphs of Rhodnius prolixus. J Medical Entomology dentin collagenous matrix prior to mineralization. J
2009;46 (3): 511-5 . Struct Biol 2000; 132(4) :212-225.
3. Santos FA, Rao VSN. "Antiinflammatory and
antinociceptive effects of 1,8-cineole a terpenoid oxide
present in many plant essential oils" Phytotherapy
research; 2000: 14 (4): 240-4.
4. Gilles M, Zhao J, An, Min; Agboola, Samson .
"Chemical composition and antimicrobial properties
of essential oils of three Australian Eucalyptus
species". Food Chemistry 2009;119 (2): 731–7.
5. Wong KC. Composition of the essential oil of
rhizomes of kaempferia galanga L. Flavour and
Fragrance J 2006; 44 (5): 263–6.
6. Partanen AM, Kiukkonen A, Sahlberg C, Alaluusua S,
Thesleff I, Pohjanvirta R, Lukinmaa P-L.
Developmental toxicity of dioxin to mouse embryonic
teeth in vitro: Arrest of tooth morphogenesis involves
stimulation of apoptotic program in the dental
epithelium. Toxicol Appl Pharmacol 2004; 194(9):24–
33.
7. Hutt AJ, Sangster SA, Caldwell J & Smith R. The
metabolic disposition of [methoxy-14C]-labelled trans-
anethole, estragole and p-propylanisole in human
volunteers. Xenobiotica 1983; 17(7):1244–55.
8. Sangster SA, Caldwell J, Hutt AJ, & Smith R. The
metabolic disposition of [methoxy-14C]-labelled trans-
anethole, estragole and p-propylanisole in human
volunteers. Xenobiotica 1987; 17(7): 1223–32 .
9. Song RFCP, Law FYY & Chakrabarti S. Disposition
and metabolism of diphenyl ether in rats. Xenobiotica.
1983; 13(2): 627–33.
10. Chui YC, Addison RF, Law F. Studies of the
pharmacokinetics and metabolism of 4-
chlorodiphenyl ether in rats. Drug Metab Dispos 1987;
15(4): 44–50.
11. Komsta E, Chu I, Villeneuve DC, Benoit FM,
Murdoch D. Tissue distribution metabolism and
excretion of 2,2’,4,4’,5-pentachlorodiphenyl ether in
the rat. Arch Toxicol 1998; 62(6): 258–62.
12. Alaluusua S, Lukinmaa PL, Pohjanvirta R, Unkila M,
Tuomisto J. Exposure to 2,3,7,8-tetrachlorodibenzo-
para-dioxin leads to defective dentin formation and
pulpal perforation in rat incisor tooth. Toxicology
1993; 81(5):1-13.
13. Gao Y, Sahlberg C, Kiukkonen A, Alaluusua S,
Pohjanvirta R, Tuomisto J, Lukinmaa P-L. Lactational
exposure of Han/Wistar rats to 2,3,7,8-
tetrachlorodibenzo-p-dioxin interferes with enamel
maturation and retards dentin mineralization J Dent
Res 2004; 83(11) :139–44 .
14. Salmela E, Sahlberg C, Alaluusua S, Liisa Lukinmaa
P.Tributylin Impairs Dentin Mineralization and
Enamel Formation in Cultured Mouse Embryonic
Molar Teeth. Toxicological Sciences
2008;106(1):214-22 .
15. Tsukamoto Y, Ishihara Y, Miyagawa-Tomita S,
Hagiwara H. Inhibition of ossification in vivo and
differentiation of osteoblasts in vitro by tributyltin.
Biochem. Pharmacol. 2004; 68(3):739–46.
16. Beniash E, Traub W, Veis A, Weiner S. A
transmission electron microscope study using vitrified
ice sections of predentin: structural changes in the

Oral Diagnosis 66
J Bagh College Dentistry Vol. 23(3), 2011 Prevalence, sex distribution

Prevalence, sex distribution of oral lesions in patients

attending an oral diagnosis clinic in Sulaimani University
Shanaz M. Gaphor B .D.S., M.Sc, Ph.D (1)
Mustafa J. Abdullah B.D.S., M.Sc. (1)

ABSTRACT
Background: Oral lesions prevalence studies are important to know the state of health and the needs of treatment.
The age, gender, educational, socioeconomic, and cultural levels, smoking, medications used, and systemic
diseases are factors that could predispose the presence of oral lesions. The present study was designed to determine
the prevalence of oral lesions in patients who visit the Oral Diagnosis Clinic of the College of Dentistry, University of
Sulaimani.
Patients and methods: This prospective study was performed on 3144 patients from July 2009-July 2010. In this study a
total of 3144 patients were examined. Of these 1507 (47.93%) were males and 1637 (52.06%) females. The patients'
age ranged between 10 to 79 years. An interview was conducted to collect information using a structured
questionnaire which was completed by each patient. The lesions that could not be diagnosed by clinical
examination alone were analyzed histopathologically.
Results: Among the 3144 patients, only 799 patients (25.41%) had one or more oral lesions. The number of oral lesions
was 905. Females constituted 49.81% (n=398) and males 50.18% (n=401). Oral lesions were classified according to the
following seven categories: tongue lesions (9.70%), anatomic changes (8.71%), white lesions (4.8%), ulcerated lesions
(3.1%), candidiasis (1.3%), benign lesions (1.05%) and malignant lesions (0.03%). Tongue lesions were highly
significantly more common among males (12.07%) than in females (7.51%). Denture stomatitis, Denture induced
fibrous hyperplasia, and Torus palatinus were significantly more common among females than in males (P<0.05),
while hairy tongue, Ankyloglossia, Fordyce granule were highly significantly more common among males than in
females. Linea alba was highly significantly more common among females (5.86%) than in males (3.64%).
Conclusion: Routine examinations of oral cavities are valuable in identifying several oral lesions and this will help to
establish early diagnosis and treatment and better prognosis particularly early precancerous and other oral lesions.
Keywords: Abnormalities, oral mucosal lesions, prevalence. (J Bagh Coll Dentistry 2011;23(3): 67-73).

INTRODUCTION
Oral health is important to the quality of life
of all individuals. Oral lesions can cause
discomfort or pain that interferes with
mastication, swallowing, and speech. Oral lesions
can produce symptoms such as halitosis,
xerostomia, or oral dysesthesia, which interfere
with daily social activities (1). Oral disease is a
health problem that is not only a matter of oral
hygiene and local condition, but can also be a
precursor to other dangerous and potentially life
threatening illnesses (2). Diagnosis of wide variety
of lesions that occur in the oral cavity is an
essential part of dental practice. An important
element in establishing a diagnosis is knowledge
of the lesions’ relative frequency, or prevalence at
one point in time (3). Among the broad spectrum
of causes leading to changes in the oral mucosa
are infections from bacteria, fungi, viruses,
parasites, and other agents; physical and thermal
influences, changes in the immune system,
systemic diseases, neoplasia, trauma and other
factors, some of which are issues of aging (4,5).
(1) College of dentistry, university of Sulaimania.
Traditionally, the mucosal membrane of the
oral cavity has been looked upon as mirroring the
general health (6). The tongue lesions fissured,
geographic and hairy tongue, oral lesions Fordyce
granules, and leukoedema are classically
considered to be developmental oral lesions rather
than having virtual disease characteristics (6).
Dental factors (poor oral hygiene, sharp teeth, and
improperly fitting dentures) have been thought to
play a role in the occurrence of oral mucosal
lesions (4,7). Denture wearers, besides suffering the
characteristic lesions from the dentures, they
present traumatic ulcerations with more frequency
than nonusers, candidosis pathology occupying
second place in frequency (8). The present study
was designed to determine the prevalence and sex
distribution of oral lesions in patients who visit
the Oral Diagnosis Clinic of the College of
Dentistry, University of Sulaimani.
PATIENTS AND METHODS
Evaluation basis: This prospective study was
performed on 3144 patients, of these 1507
(47.93%) were males and 1637 (52.06%) were
females. The patients' ages were between 10 to 79
years. All patients included in this study were
referred to the Department of Oral Medicine,
College of Dentistry, University of Sulaimani

Oral Diagnosis 67
J Bagh College Dentistry Vol. 23(3), 2011
from July 2009-July 2010. The bases for attending
to the clinic were to seek dental treatment.
Patients
An interview was conducted to collect
information using a structured questionnaire
which was completed by each patient and the
examiner. Both dental and general medical
histories of the patients were obtained.
Methods
The patients were examined clinically by two
trained examiner using artificial light, mouth
mirror, gauze. At the time of clinical examination,
we established a preliminary diagnosis. Some of
the mucosal changes where diagnosed solely by
clinical examination (e.g. linea alba, fissured
tongue, etc.). Some times a cotton swab was used
to remove evident debris; a swab was always used
to test whether a white lesion could be wiped off.
In some cases where the observed lesion could be
of traumatic origin, this was eliminated and the
patients were requested to return for evaluation 15
days later for a new exploration. During the
clinical examination, the following elements
including features of the lesion, anatomical
location, extension, etiological factors or related
factors, dental status were analyzed. The
diagnosis was made based on history, clinical
features, and investigations according to the WHO
(1997) criteria (9). When clinical features were
not diagnostic and where no clinical improvement
was observed, a biopsy was undertaken.
RESULTS
Among the 3144 patients, only 799 patients
(25.41%) had oral lesions. Females constituted
49.81% (n=398) and males 50.18% (n=401). The
age range of the patients was between 10-79
years. Nine hundred five oral lesions were
detected. Oral lesions were slightly more
prevalent among males (26.60%) than females
(24.31%), but the difference was not statistically
significant. Oral lesions were classified according
to the following 7 categories: tongue lesions
(9.70%), anatomic changes (8.71%), white lesions
(4.8%), ulcerated lesions (3.1%), candidiasis
(1.3%), benign lesions (1.05%) and malignant
lesions (0.03%).
Prevalence and sex distribution of tongue
lesions: Table 1 shows the distribution of tongue
lesions prevalence according to patient's sex.
Tongue abnormalities were present in 9.70%
(n=305) of the total sample. Tongue lesions were
highly significantly more common among males
(12.07%) than in females (7.51%). The most
common tongue condition was fissured tongue,
constituting about 5.24 % of all tongue conditions.
Other tongue lesions include Black hairy tongue
Oral Diagnosis
Prevalence, sex distribution
(1.87%), ankyloglossia (1.08%), lingual
varicosities (0.82), geographic tongue (0.57) and
scalloped tongue (0.09) consequently as shown in
table 1.
Prevalence and sex distribution of anatomic
changes: Table 2 shows the distribution of
anatomic changes prevalence according to
patient's sex. Anatomic changes were observed in
8.71% of the patients. The most common
anatomic changes were Linea alba (White line).
Linea alba (White line) was seen in 4.80%. Other
anatomic changes include Fordyce's granules
(3.56%), torus mandibularis (0.19%) and torus
palatinus (0.15%) consequently as shown in table
2.
Prevalence and sex distribution of white
lesions: Table 3 shows the distribution of white
lesions prevalence according to patient's sex.
White lesions were observed in 4.8% of all
patients. The most common white lesion was
Cheek biting. Cheek biting was seen in 3.49% of
all patients. Other white lesions include Frictional
(traumatic keratosis) (0.82%), oral lichen planus
(0.25%), leukoplakia (0.09%), nicotine stomatitis
(0.06%), actinic keratosis (cheilitis) (0.03%) and
lichenoid reaction (0.03) consequently as shown
in table 3.
Prevalence and sex distribution of ulcerative,
vesicular and bullous lesions: Table (4) shows
the distribution of ulcerative, vesicular and
bullous lesions prevalence according to patient's
sex. Ulcerative, vesicular and bullous lesions were
diagnosed in 3.1% of the studied populations. The
most common ulcerative lesion was recurrent
aphthous stomatitis. Recurrent aphthous stomatitis
was seen in 1.68% of all patients. Other
ulcerative, vesicular and bullous lesions include
recurrent herpes simplex virus infection (0.69%),
traumatic ulcer (0.69%), Behçet’s Syndrome
(0.03%) and erythema multiformi (0.03%)
consequently as shown in table 4.
Prevalence and sex distribution of candidiasis:
Table 5 shows the distribution of candidiasis
prevalence according to patient's sex. Candidiasis
was observed in 1.3% of all patients. The most
common candidal infection was denture
stomatitis. Denture stomatitis was seen in 0.73%
of all patients. Other candidiasis includes angular
cheilitis (0.28%), median rhomboid glossitis
(0.25%) and acute pseudomembranous candidiasis
(thrush) (0.03%) consequently as shown in table
(5).
Prevalence and sex distribution of benign
lesions: Table 6 shows the distribution of benign
lesions prevalence according to patient's sex.
Benign lesions were diagnosed in 1.05% of the
studied population. The most common benign
68
J Bagh College Dentistry Vol. 23(3), 2011
lesions were Fibroepithelial hyperplasia.
Fibroepithelial hyperplasia was seen in 0.38% of
all patients. Other benign lesions include denture
induced fibrous hyperplasia (0.34%) , peripheral
giant cell granuloma (0.06%), gingival
hyperplasia (0.09%), mucoceles (0.09%),
radicular cyst (0.06%) and port wine stain
(0.03%) consequently as shown in table 6.
Prevalence and sex distribution of malignant
lesions: Squamous cell carcinoma was seen in
0.03% of the studied population.
DISCUSSION
Epidemiological studies performed over the
past few years have shown considerable variation
in the prevalence of oral mucous lesions among
different regions throughout the world (10). There
are considerable methodological problems
because of the absence of standard protocols and
the wide variation in the methods used.
Consequently, the prevalences found for each
lesion vary widely among research groups (10).
Among 3144 patients, 799 patients (25.41%)
had one or more oral lesions, a result comparable
with that in a study by Rooban et al. (11) in
Chennai, south India (25%), but lower than that in
other studies done by Garcia-pola Vallejo et al.
(12)
among an adult Spanish population (51.1%),
and more than that found by Saraswathi et al. (13)
in a cross-sectional study in south India (4.1%).
These variations could be explained due to:
Geographical factors, Different methodologies
used, Sex distribution of the sample, Age
distribution of the sample, Specific cultural habits
like smoking and use of alcohol, Variation in the
clinical interpretation of parameters, Real
differences in the prevalence of oral lesions,
Racial factor, Educational level of the patients,
Socioeconomic factors, Cultural levels,
Medication used, Systemic diseases, use of
dentures, Food type and the number and type of
the lesion included in the study, because recording
all oral mucosal lesions detected during a physical
examination clearly results in a high prevalence of
oral mucosal disease. Oral lesions were slightly
more prevalent among males (26.60%) than in
females (24.31%). This is in agreement with the
finding of Pentenero et al. (14) in Turin area but
disagrees with the finding of Al-mobeeriek and
Aldosari (15) among Saudi dental patients in which
oral lesions where more prevalent in females than
in males.
Prevalence, sex distribution of tongue lesions:
Tongue abnormalities were present in 9.70%
(n=305) of the total sample. Tongue lesions were
highly significantly more common among males
(12.07%) than in females (7.51%). This is in
Oral Diagnosis
Prevalence, sex distribution
agreement with the finding of Avcu and Kanli (16)
among Turkish dental outpatients. Our result
disagrees with the finding of Al-mobeeriek and
Aldosari (15) where tongue lesions were higher
among females than males and it was not
statistically significant. The most common tongue
condition was fissured tongue, constituting about
54.09% of all tongue conditions. This is in
agreement with the finding of Al-mobeeriek and
Aldosari (15) and disagrees with the finding of
Mojarrad and Vaziri (17) in Hamadan, Iran.
Fissured tongue was observed in 5.24% of all
patients. This is comparable to the finding by
Mathew et al. (18) in southern India (5.7%), and it
is more than that found by Al-mobeeriek and
Aldosari (15) in Saudi Arabia (1.41%). Fissured
tongue was more prevalent among males (5.90%)
than in females (4.64%) however, sex differences
were not statistically significant which are in
agreement with the finding of Mojarrad and
Vaziri (17). Black hairy tongue was seen in 1.87%.
This prevalence is comparable to the finding Al-
mobeeriek and Aldosari (15) (0.55%), and inferior
to that observed in a cross-sectional study in
Jahanbani et al.(6) (8.9%) in Iran. Ankyloglossia
was diagnosed in 1.08%. This prevalence is
comparable to the finding by Mojarrad and Vaziri
(17)
(0.8%), and Al-mobeeriek and Aldosari (15).
Ankyloglossia was highly significantly more
common among males (1.59%) than in females
(0.61%). This is in agreement with the finding of
Ricke et al. (19). Lingual varicosities were seen in
0.82% of the studied population. This prevalence
is comparable to the finding by Mathew et al. (18)
in southern India, Al-mobeeriek and Aldosari (15)
(0.39%).Geographic tongue was seen in 0.57% of
all patients. This prevalence is comparable to the
finding by Mathew et al. (18) (0.84%), Al-
mobeeriek and Aldosari (15) (0.51%).Geographic
tongue was more prevalent in females (0.67%)
than in males (0.46%), however sex difference
was not statistically significant. Among the
patients with geographic tongue 61.11% also had
fissured tongue, while 6.66% of the patients with
fissured tongue had geographic tongue. Similarly,
Voros-Balog et al. (20) found that among the
children with geographic tongue 44.82% also had
fissured tongue, while 8.75% of the children with
fissured tongue had geographic tongue.
Prevalence, sex distribution analysis of
anatomic changes: Anatomic changes were
observed in 8.71% of the patients. Linea alba
(white line) was seen in 4.80%. It was highly
significantly more common among females
(5.86%) than in males (3.64%). This prevalence is
comparable to the finding by Cebeci et al. (21) in
Turkey (4.2%), but it is lower than that found by
69
J Bagh College Dentistry Vol. 23(3), 2011
Martinez and Garcia pola (8) (10.1%). Fordyce
granule was seen in 3.56% of all patients. This is
comparable to the finding by Al mobeeriek and
Aldosari (15) (3.84%), and Cebeci et al. (21) in
Turkey (2.8%). Fordyce granules was highly
significantly more common among males (5.44%)
than in females (1.83%) which is in agreement
with the finding of Jahanbani et al. (6) in Iran, but
conflicts with the finding of Al-mobeeriek and
Aldosari (15) in which Fordyce granules were
significantly more common in females. Fordyce
granules may be a target of the androgenic
hormones (22). Torus mandibularis (TM) was
observed in 0.19%. This is comparable to the
finding by Al-mobeeriek and Aldosari (15) (0.08%)
and less than that found by Nair et al. (23) in
Vietnamese population (3%). Torus mandibularis
(TM) was more prevalent in females (0.30%) than
in males (0.06%) however, sex differences was
not statistically significant which is in agreement
with the finding of Al-mobeeriek and Aldosari
(15)
and disagrees with the finding of Ihunwo and
Phukubye (24) in Black South African population.
Torus platinus (TP) was diagnosed in 0.15% of all
patients. This prevalence is lower than that found
by Al-mobeeriek and Aldosari (15) (1.33%). The
reason for the variation in the prevalence of torus
palatinus (TP) was thought to be environmental,
genetic and functional factors which are important
for this prevalence. Torus platinus (TP) was
significantly more common among females
(0.30%) which are in agreement with the finding
of Sisman et al. (25) in Turkey.
Prevalence, sex distribution of white lesions:
White lesions were observed in 4.8% of all
patients. Cheek biting was seen in 3.49% of all
patients. This is comparable to the finding by
Shulman et al. (3) in US adults (3.05%). Frictional
(traumatic) keratosis was seen in 0.82% of all
patients. This is comparable to the finding of Al-
mobeeriek and Aldosari (15) (0.90%), but lowers
than that found by Garcia-pola Vallejo et al. (12) in
an adult Spanish population (7.5%). Frictional
keratosis was more prevalent in males (0.92%)
than in females (0.73). The higher prevalence of
frictional keratosis among males is in agreement
with the finding of Mathew et al. (18) in southern
India and Al-mobeeriek and Aldosari (15). Oral
lichen planus was seen in 0.25% of all patients.
This is comparable to the finding by Saraswathi et
al. (13) (0.15%), and Al-mobeeriek and Aldosari
(15)
(0.35%). The high prevalence of oral lichen
planus among females is in agreement with the
finding of Martinez and Garcia pola (8) and
Mathew et al. (18). Leukoplakia was seen in
0.09%. This is comparable to the finding by
Cebeci et al. (21) in Turkey (0.4%), but it is lower
Oral Diagnosis
Prevalence, sex distribution
than that of several other studies done by Rooban
et al. (11) in Chennai, south India (7.4%).
Leukoplakia was found only in males (0.19%)
however, sex difference was not statistically
significant which is in agreement with the finding
of Lapthanasupkul et al. (26) in a Thai population.
Prevalence, sex distribution of ulcerative,
vesicular, and bullous lesions: Ulcerative,
vesicular, and bullous lesions were diagnosed in
3.1% of the studied populations. Recurrent
aphthous stomatitis was seen in 1.68%. This is
comparable to the finding by Shulman (27) in the
USA (1.64%), Mathew et al. (18) (2.1%).
Recurrent aphthous stomatitis was more prevalent
in females (1.77%) than in males (1.59%). Similar
finding has been reported by Lin et al. (28) in adult
Chinese, and disagrees with the finding of
Mathew et al. (18) in which RAS was more
frequent in males (2.27%) than in females (1.8%).
Recurrent herpes labialis (RHL), the common
cold sore or fever blister was observed in 0.69%.
This is comparable to the finding by Mathew et
al. (18) in India (0.58%) and Al-mobeeriek and
Aldosari (15) (0.27%) The higher prevalence of
recurrent herpes simplex virus infection among
females in which (0.73% among females and
0.66% among males) is in agreement with the
finding of Mathew et al. (18), Al-mobeeriek and
Aldosari (15). The most common cause of single
ulcers on the oral mucosa is trauma. Trauma may
be caused by teeth, food, dental appliances, dental
treatment, heat, chemicals, or electricity (29).
Traumatic ulcer was seen in 0.69%. This
prevalence is comparable to the finding by
Mathew et al. (18) (1.008%), Cebeci et al. (21) in
Turkey (0.9%). Traumatic ulcer was more
prevalent in females (0.85%) than in males
(0.53%).
Prevalence, sex distribution of Candidiasis:
Candidiasis was observed in 1.3% of all patients.
Denture stomatitis was seen in 0.73%. This
prevalence is comparable to the finding by
Mathew et al. (18) (0.84%). Denture stomatitis was
significantly more common among females than
in males (1.09% and 0.33% respectively). This is
in agreement with the finding of Dos Santos et al.
(30)
among south Brazilian older adults. Angular
cheilitis was seen in 0.28% of all patients. This
prevalence is in accordance with the study done
by Al Jubori (31) among Iraqi patients (0.4%), but
it is lower than that of several other studies done
by Espinoza et al. (32) in an elderly people in
Santiago, Chile (2.9%). Angular cheilitis was
more prevalent in males (0.33%) than in females
(0.24%). Median rhomboid glossitis was seen in
0.25%. This study is comparable to the finding by
Mojarrad and Vaziri (17) in Hamadan, Iran (0.2%),
70
J Bagh College Dentistry Vol. 23(3), 2011
but lowers than that found by Mathew et al. (18)
(1.5%). The higher prevalence of median
rhomboid glossitis among males in which (0.39%
male and 0.12% female) is in agreement with the
finding of Mathew et al. (18).
Prevalence, sex distribution of benign lesions:
Benign lesions were diagnosed in 1.05% of the
studied population. Fibroepithelial hyperplasia
was seen in 0.38%. This is comparable to the
finding by Mathew et al. (18) (0.84%), and Cebeci
et al. (21) (0.6%) and lower than that found by
Espinoza et al. (32) in Santiago, Chile (9.4%).
Fibroepithelial hyperplasia was more prevalent in
females (0.42%) than in males (0.33%). Denture
induced fibrous hyperplasia was seen in 0.34% of
all patients which is comparable with the finding
of Cebeci et al. (21) in an adult Turkish population
(0.2%) and it is lower than that found by Martinez
and Garcia-pola (8) (5%). Denture induced fibrous
hyperplasia was significantly more common
among females (0.61%) than in males (0.06%).
This is in agreement with the finding of Zarei et
al. (33) in Kerman province, Iran. Peripheral giant
cell granuloma (PGCG) was diagnosed in 0.06%.
In a study by Chen et al. (34) among a population
from southern Taiwan PGCG form 0.1% of
trauma-associated soft tissue lesions. Mucoceles
was observed in 0.09% of the studied population.
This is comparable to the finding by Espinoza et
al. (32) in Santiago, Chile (0.2%).
Prevalence, sex distribution of malignant
lesions: Squamous cell carcinoma was seen in
0.03% of the studied population. This is
comparable with the finding of Cebeci et al. (21) in
an adult Turkish population (0.06%). Campisi
and Margiotta (7) found that of 180 patients, only 1
had Squamous cell carcinoma (0.9%). The lower
prevalence of squamous cell carcinoma in our
study is probably because many patients with oral
cancer go to the Department of Oral and
Maxillofacial Surgery in the Teaching Hospital
and only few cases of oral cancer are diagnosed at
the university.
REFERENCES
1- Triantos Dimitris. Intra-oral findings and general
health conditions among institutionalized and non-
institutionalized elderly in Greece. J Oral Pathol Med
2005; 34 (10): 577 – 82.
2- Soames JV, Southam EJ. Oral Pathology. 4th Ed. New
York: Oxford University press Inc 2005.
3- Shulman JD, Beach MM, Rivera-Hidalgo F. The
prevalence of oral mucosal lesions in U.S. adults Data
from the Third National Health and Nutrition
Examination Survey, 1988-1994. J Am Dent Assoc
2004; 135: 1279-86.
4- Reichart PA. Oral mucosal lesions in a representative
cross-sectional study of aging Germans. Community
Dent Oral Epidemiol 2000; Oct: 28(5):390-8.
Oral Diagnosis
Prevalence, sex distribution
5- Jainkittivong A, Aneksuk V, Langlais RP. Oral
mucosal conditions in elderly dental patients. Oral Dis
2002; Jul: 8(4):218-23
6- Jahanbani J, Sandvik L, Lyberg T, Ahlfors E.
Evaluation of Oral Mucosal Lesions in 598 Referred
Iranian Patients. The Open Dent J 2009; 3: 42-7.
7- Campisi G, Margiotta V. Oral mucosal lesions and
risk habits among men in an Italian study population. J
Oral Pathol Med 2001; Jan: 30(1):22-8.
8- Martínez AI, García-Pola MJ. Epidemiological study
of oral mucosal pathology in patients of the Oviedo
School of Stomatology. Med Oral 2002; 7(1): 4-16.
9- WHO. Oral health surveys, basic methods, Criteria for
the examination of the oral mucosa and soft tissues. 4th
edition 1997. England, 1-66.
10- Rioboo-Crespo MR, Planells-del Pozo P, Rioboo-
García R. Epidemiology of the most common oral
mucosal diseases in children. Med Oral Patol Oral Cir
Bucal 2005; 10:376-87.
11- Rooban T, Rao A, Joshua E, Ranganathan K. The
prevalence of oral mucosal lesions in alcohol misusers
in Chennai, south India. Indian J Dent Res 2009; Jan-
Mar: 20(1): 41-6.
12- García-Pola Vallejo MJ, Martínez Díaz-Canel AI,
García Martín JM, González García M. Risk factors
for oral soft tissue lesions in an adult Spanish
population. Community Dent Oral Epidemiol 2002;
Aug: 30(4): 277-85.
13- Saraswathi TR, Ranganathan K, Shanmugam S,
Sowmya R, Narasimhan PD, Gunaseelan R.
Prevalence of oral lesions in relation to habits: Cross-
sectional study in South India. Indian J Dent Res
2006; Jul-Sep: 17(3): 121-5.
14- Pentenero M, Broccoletti R, Carbone M, Conrotto D,
Gandolfo S. The prevalence of oral mucosal lesions in
adults from the Turin area. Oral Dis 2008; May: 14(4):
356-66.
15- Al-Mobeeriek A, Aldosari AM. Prevalence of oral
lesions among Saudi dental patients. Ann Saudi Med
2009; 29(5): 365-8.
16- Avcu N, Kanli A. The prevalence of tongue lesions in
5150 Turkish dental outpatients. Oral Dis 2003; Jul:
9(4):188-95.
17- Mojarrad F, Vaziri P Bakianian. Prevalence of Tongue
Anomalies in Hamadan, Iran. Iranian J Publ Health
2008; 37(2): 101-5.
18- Mathew AL, Pai KM, Sholapurkar AA, Vengal
M. The prevalence of oral mucosal lesions in patients
visiting a dental school in Southern India. Indian J
Dent Res 2008; 19(2): 99-103.
19- Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA.
Newborn Tongue-tie: Prevalence and Effect on Breast-
Feeding. J Am Board Fam Pract 2005; 18:1-7.
20- Vörös-Balog T, Vincze N, Bánóczy J. Prevalence of
tongue lesions in Hungarian children. Oral Dis 2003;
Mar: 9(2):84-7.
21- Cebeci AR İ, Gülşahı A, Kamburoğlu K, Orhan BK,
Öztaş B. Prevalence and distribution of oral mucosal
lesions in an adult Turkish population. Med Oral Patol
Oral Cir Bucal 2009; Jun: 14 (6): E272-7.
22- Whitaker SB, Vigneswaran N, Singh BB. Androgen
receptor statusof the oral sebaceous glands. Am J
Dermatopathol 1997; 19: 415-8.
23- Nair RG, Samaranayake LP, Philipsen HP, Graham
RG, Itthagarun A. Prevalence of oral lesions in a
selected Vietnamese population. Int Dent J 1996; Feb:
46(1):48-51.
71
J Bagh College Dentistry Vol. 23(3), 2011 Prevalence, sex distribution

24- Ihunwo AO, Phukubye P. The frequency and 30- Dos Santos CM, Hilgert JB, Padilha DM, Hugo FN.
anatomical features of torus mandibularis in a Black Denture stomatitis and its risk indicators in south
South African population. Homo 2006; 57(4):253-62. Brazilian older adults. Gerodontology 2010; Jun:
25- Sisman Y, Ertas ET, Gokce C, Akgunlu F. Prevalence 27(2):134-40.
of Torus Palatinus in Cappadocia Region Population 31- Al Jubori RH. Prevalence of oral mucosal lesions in
of Turkey. Eur J Dent 2008; Oct: 2: 269–75. Iraqi patients. Iraqi Dent J 1997; 21:187-200.
26- Lapthanasupkul P, Poomsawat S, Punyasingh J. A 32- Espinoza I, Rojas R, Aranda W, Gamonal J.
clinicopathologic study of oral leukoplakia and Prevalence of oral mucosal lesions in elderly people in
erythroplakia in a Thai population. Quintessence Int Santiago, Chile. J Oral Pathol Med 2003; Nov:
2007; Sep: 38(8): e448-55. 32(10):571-5.
27- Shulman JD. Prevalence of oral mucosal lesions in 33- Zarei MR, Chamani G, Amanpoor S. Reactive
children and youths in the USA. Int J Paediatr hyperplasia of the oral cavity in Kerman province,
Dent2005; Mar: 15(2): 89-97. Iran: a review of 172 cases. Br J Oral Maxillofac Surg
28- Lin HC, Corbet EF, Lo EC. Oral mucosal lesions in 2007; Jun: 45(4):288-92.
adult Chinese. J Dent Res 2001; 80:1486-90. 34- Chen JY, Wang WC, Chen YK, Lin LM. A
29- Greenberg MS. Ulcerative, Vesicular, and Bullous retrospective study of trauma-associated oral and
lesions. In: Greenberg Martin S, Glick Michael, maxillofacial lesions in a population from southern
editors. Burket’s Oral Medicine Diagnosis & Taiwan. J Appl Oral Sci 2010; 18(1).
Treatment. 10th Ed Spain: BC Decker Inc.2003; 50-84.
Table 1: Distribution of tongue diseases prevalence according to patient's sex
Presence/ Sex
Tongue
absence Male (1507) Female (1637) Total (3144) X2
Diseases
of lesion No % No % No %
Yes 89 5.9 76 4.64 165 5.24
Fissured
No 1418 94.09 1561 95.35 2979 94.75 N.S
Tongue
Total 1507 47.93 1637 52.06 3144 100
Yes 46 3.05 13 0.79 59 1.87 X2=21.732
Black hairy
No 1461 96.94 1624 99.2 3085 98.12 d.f=1, P<0.001
Tongue
Total 1507 47.93 1637 52.06 3144 100
Yes 24 1.59 10 0.61 34 1.08 X2=7.069
Ankylo-
No 1483 98.4 1627 99.38 3110 98.91 d.f=1, P<0.01
Glossia
Total 1507 47.93 1637 52.06 3144 100

Table 2: Distribution of normal structural variants prevalence according to patient's sex

Presence/ Sex
Normal
absence Male (1507) Female (1637) Total (3144) X2
structural variants
of lesion No % No % No %
Yes 55 3.64 96 5.86 151 4.8 X2=8.418
Linea alba
No 1452 96.35 1541 94.13 2993 95.19 d.f=1, P<0.01
(White line)
Total 1507 47.93 1637 52.06 3144 100
Yes 82 5.44 30 1.83 112 3.56 X2=29.743
Fordyce’s
No 1425 94.55 1607 98.16 3032 96.43 d.f=1, P<0.001
Granules
Total 1507 47.93 1637 52.06 3144 100

Table 3: Distribution of white lesions prevalence according to patient's sex

Presence/ Sex
White lesions absence Male (1507) Female (1637) Total (3144) X2
of lesion No % No % No %
Yes 44 2.91 66 4.03 110 3.49
Cheek N.S
No 1463 97.08 1571 95.96 3034 96.5
biting
Total 1507 47.93 1637 52.06 3144 100
Frictional
Yes 14 0.92 12 0.73 26 0.82
(Traumatic) N.S
Keratosis No 1493 99.07 1625 99.26 3118 99.17
Total 1507 47.93 1637 52.06 3144 100
Oral lichen
Yes 3 0.19 5 0.3 8 0.25 N.S
planus

Oral Diagnosis 72
J Bagh College Dentistry Vol. 23(3), 2011 Prevalence, sex distribution

Table 4: Distribution of ulcerative lesions prevalence according to patient's sex

Sex
Ulcerative, vesicular Presence/
Male (1507) Female (1637) Total (3144)
and Bullous lesions absence of lesion
No % No % No % X2
Yes 24 1.59 29 1.77 53 1.68
Recurrent aphthous N.S
No 1483 98.4 1608 98.22 3091 98.31
stomatitis
Total 1507 47.93 1637 52.06 3144 100
Yes 10 0.66 12 0.73 22 0.69
Recurrent herpes N.S
No 1497 99.33 1625 99.26 3122 99.3
simplex virus infection
Total 1507 47.93 1637 52.06 3144 100
Traumatic ulcer Yes 8 0.53 14 0.85 22 0.69 N.S

Table 5: Distribution of candidiasis prevalence according to patient's sex

Presence/ Sex
Candidiasis absence Male (1507) Female (1637) Total (3144) X2
of lesion No % No % No %
Denture Yes 5 0.33 18 1.09 23 0.73 X2=6.369
stomatitis No 1502 99.66 1619 98.9 3121 99.26 d.f=1, P<0.05
Total 1507 47.93 1637 52.06 3144 100
Angular Yes 5 0.33 4 0.24 9 0.28
N.S
cheilitis No 1502 99.66 1633 99.75 3135 99.71
Total 1507 47.93 1637 52.06 3144 100

Table 6: Distribution of benign lesions prevalence according to patient’s sex

Sex
Presence/
Inflammatory (reactive) Male Female Total
absence of X2
hyperplasia (1507) (1637) (3144)
lesion
No % No % No %
Yes 5 0.33 7 0.42 12 0.38
Fibro epithelial N.S
No 1502 99.66 1630 99.57 3132 99.61
hyperplasia
Total 1507 47.93 1637 52.06 3144 100
Yes 1 0.06 10 0.61 11 0.34 X2=6.673
Denture induced d.f=1,
No 1506 99.93 1627 99.38 3133 99.65
fibrous hyperplasia P<0.05
Total 1507 47.93 1637 52.06 3144 100
Yes 2 0.13 0 0 2 0.06
Peripheral giant N.S
No 1505 99.86 1637 100 3142 99.93
cell granuloma
Total 1507 47.93 1637 52.06 3144 100

Oral Diagnosis 73
J Bagh College Dentistry Vol. 23(3), 2011 The study of oral manifestations

The study of oral manifestations, oxidative stress marker

and antioxidants in serum and saliva of rheumatoid
arthritis patients
Zahra K. Hadi B.D.S. (1)
Tagreed F. Zaidan B.D.S, M.Sc, Ph.D.(2)

ABSTRACT
Background: Rheumatoid arthritis (RA) is a heterogeneous disease with a spectrum of clinical severity ranging from
mild arthritis to a crippling joint disorder with internal organ involvement. Besides the immunological reaction, there is
another biological process, based on the injurious activity of free radicals, playing a major role in the pathogenesis;
an increase in the generation of oxidants and lipid peroxidation products was demonstrated in the serum of RA
patients, which correlated with the antioxidant levels.
Subjects, Materials and Methods: Seventy six individuals were enrolled in this study; Fifty one of them were patients
having RA; twenty five were healthy control individuals matching the patients in age and sex. Serum and saliva
samples have been taken from each subject for biochemical analysis.
Results: The highest number of RA patients was of mild disease activity, while the lowest number was of inactive
disease activity. Xerostomia was the most prominent oral manifestations of RA patients. The mean of serum and
saliva MDA and UA in RA patients was significantly higher than of the healthy controls. The mean of serum and saliva
caeruloplasmin in RA patients was higher than that of the healthy controls.
Conclusion: Rheumatoid arthritis patients were associated with increased oxidative stress, antioxidants and
inflammatory markers.. Patients with RA have different oral manifestations xerostomia were the most prominent. The
highest number of RA patients was of mild disease activity.
Key words: rheumatoid arthritis, oxidative stress, DAS, saliva flow rate. (J Bagh Coll Dentistry 2011;23(3): 74-79).

INTRODUCTION
Rheumatoid arthritis (RA) is a chronic,
systemic inflammatory disorder that may affect
many tissues and organs, but principally attacks
synovial joints. The process produces an
inflammatory response of the synovium
(synovitis) secondary to hyperplasia of synovial
cells, excess synovial fluid, and the development
of pannus in the synovium. The pathology of the
disease process often leads to the destruction of
articular cartilage and ankylosis of the joints (1).
Rheumatoid arthritis is a form of autoimmunity,
the causes of which are still incompletely known.
It is a systemic (whole body) disorder principally
affecting synovial tissues (2). Rheumatoid arthritis
affects women three times more often than men,
and it can first develop at any age. The risk of first
developing the disease (the disease incidence)
appears to be greatest for women between 40 and
50 years of age, and for men somewhat later (3).
The most important diagnostic criteria for RA
patients are morning stiffness, arthritis and soft
tissue swelling (4). There is no known cure for
rheumatoid arthritis, but many different types of
treatment can alleviate symptoms and/or modify
the disease process.
(1) MSc Student, College of Dentistry, Baghdad University.
(2) Assist. Professor, department of oral medicine, college of
dentistry, Baghdad University.
Pharmacological treatment of RA can be
divided into disease-modifying antirheumatic
drugs (DMARD), Cortisone therapy, biological
agents and anti-inflammatory agents and
analgesics. Treatment also includes rest and
physical activity(5). The course of the disease
varies greatly. Some people have mild short-term
symptoms, but in most the disease is progressive
for life. Around 20%-30% will have subcutaneous
nodules (known as rheumatoid nodules); this is
associated with a poor prognosis (6).Oral
manifestations of RA patients include TMJ
disorders, xerostomia and Sjogren's syndroms.
Also RA patients have oral manifestations as a
side effect of treatment includes: Aphthous
stomatitis, Glossitis, Oral ulceration, Lichenoid
eruptions, oral pigmentation, Angular Cheilitis
and Candidal infection (7). Oxidative stress
represents an imbalance between the production
of reactive oxygen species and a biological
system's ability to readily detoxify the reactive
intermediates or to repair the resulting damage.
An antioxidant is a molecule capable of inhibiting
the oxidation of other molecules. Oxidation
reactions can produce free radicals. In turn, these
radicals can start chain reactions that damage
cells. Antioxidants terminate these chain reactions
by removing free radical intermediates, and
inhibit other oxidation reactions. They do this by
being oxidized themselves, so antioxidants are
often reducing agents (8). Oxidative stress is
thought to contribute to the development of a

Oral Diagnosis 74
J Bagh College Dentistry Vol. 23(3), 2011
wide range of diseases including rheumatoid
arthritis, it is unclear if oxidants trigger the
disease, or if they are produced as a secondary
consequence of the disease and from general
tissue damage. In the case of rheumatoid arthritis,
rheumatoid factor binds IgG when it is exposed to
free radicals. This binding stimulates the
production of more free radicals which then attack
the cartilage matrix (9).
MATERIALS AND METHODS
Seventy six subjects were enrolled in this
study, they were divided into 2 groups:- Fifty-one
patients were diagnosed clinically ,by
rheumatology specialist as rheumatoid arthritis
depending on the seven criteria of the American
Rheumatism Association (ARA)(4) that are
mentioned before, their ages ranged between 17-
65 years, they were 12 males and 39 females.
Rheumatoid arthritis patients with other systemic
diseases such as diabetes mellitus, hypertension or
other cardiovascular disease should be excluded;
also patients with periodontitis (because
periodontitis may increase the saliva oxidative
stress) were excluded. Rheumatoid arthritis
patients were subdivided into subgroups:-a-
Newly diagnosed patients. The duration of the
disease was less than 6 weeks. (Patients without
any type of treatment; they were 30 patients).b-
Old diagnosed patients (patients mainly on
methotrexate treatment the dose was 1cc/week;
they were 21 patients).
Twenty-five individuals were age and sex
matched healthy looking volunteers with no signs
and symptoms of any systemic disease and with
no periodontitis. Including 9 males and 16
females, their age ranges between (20-60) years.
Each patient was examined by rheumatologist
and each tender and or swollen joint was
calculated according to the CDAI. According to
this index the patients were subdivided to inactive
or remision if the CDAI < 2.8, mild or low disease
activity if the CDAI was 2.8-10, moderate disease
activity if the CDAI was 10-22, and sever disease
activity if the CDAI was more than 22. Intraoral
examination was done for each individual using
sterile dental mirrors, sterile dental probes and
artificial light. Examination of oral mucosal
changes: - The examination was begun with the
lips proceeding to the right buccal mucosa,
including the upper and lower sulcus, retro molar
area, the upper and lower labial mucosa, the left
buccal mucosa, the palatal mucosa and the
surface, margins of the tongue with the inferior
surface of the tongue and the floor of the mouth
were examined. All clinically evident mucosal
alteration (redness, swelling, ulcer …etc) were
Oral Diagnosis
The study of oral manifestations
determined and recorded, to find any oral
manifestations. Examination of the
temperomandibular joint also done and all
clinically evident changes (clicking, limitation,
dislocation…etc) were determined and recorded.
About 6 ml of venous blood sample were
aspirated from anticubital vein of each individual,
using plastic disposable syringes with 21 gauge
stainless steel needle; 2ml of blood was
immediately transferred to a tube containing 0.4
ml sodium citrate. The remaining blood was
transferred to polyethylene plain tube. Serum was
obtained by centrifugation at 3000 rpm for 10
minutes, transferred immediately into another
tube and frozen at (-20ºC) for subsequent
analysis. Haemolyzed samples were discarded.
Unstimulated (resting) whole saliva was
collected after an individual was asked to rinse his
mouth thoroughly with water to allow removal of
debris. The first mouth –full of saliva was
discarded to allow clearance of water. Then they
were asked to spit all the saliva during 10 minutes
into plastic graduated tubes, saliva flow rate was
immediatly calculated as the volume of saliva in
ml divided by the time in minutes required for
collection of saliva.
Saliva flow rate (ml\min) =
The collected saliva was centrifuged at 3000
rpm for 10 minutes; the clear supernatants were
separated and stored frozen at about (-20ºC) until
assayed.
RESULTS
Age and Gender: Fifty one patients with
rheumatoid arthritis (RA) were incorporated in
this study , 12 patients (23.5%) were males and 39
patients (76.5%) were females , 30 patients were
of newly diagnosed without any treatment and 21
RA patients were old diagnosed , they were
mainly on methotrexate treatment. The mean age
of RA patients was 40.4± 14.9 years. Twenty five
healthy control subjects were included in this
study they were 9 (36.0%) males and 16 (64.0%)
were females. The mean age of healthy controls
was 36.4 ± 11.8 years (table 1)
CDAI: According to the CDAI the RA patients
were classified into inactive (remission), mild
(low disease activity), and moderate disease
activity and sever disease activity depending on
number of swelling and tender joints.
Table (2) showed that the highest number 18
(35.3%) of RA patients were of mild disease
activity, while the lowest number 5 (9.8%) of RA
patients were of inactive (remission) disease
activity.
75
J Bagh College Dentistry Vol. 23(3), 2011
Saliva flow rate: The results showed that the
salivary flow rate in healthy controls was
significantly higher (0.8 ml\min) than that in RA
patients (0.4 ml\min) (P < 0.001) as shown in
figure 1.
Oral manifestations and TMJ disorders:- Each
patient was examined extraorally and intraorally,
the results revealed that the main oral
manifestations of RA patients were angular
chilitis and candidal infection, TMJ disorder, oral
ulceration, and xerostomia. Xerostomia was the
most prominent oral manifestations of RA
patients which was found in 25 (49%) patients
followed by TMJ disorders in 23 (45%) patients,
then oral ulceration and angular cheilitis and
candidal infection which was found in 15 (29.4%)
patients. (Figure 2).
Oxidative stress marker Malondialdehyde (MDA)
The mean of serum MDA in RA patients (5.6
µmol\L)was significantly higher (P<0.001) than
that of the healthy controls (2.7µmol\L), also the
mean of saliva MDA in RA patients (4.8µmol\L)
was significantly higher (P < 0.001) than that of
the healthy controls (1.8µmol\L). (Figure 3).
Caeruloplasmin (CP) The mean of serum
caeruloplasmin in RA patients (0.3gm\L) was
significantly higher (P < 0.001) than that of the
serum healthy controls (0.1gm\L).Although the
mean of saliva caeruloplasmin in RA patients
(0.06gm\L) was higher than that of the healthy
controls (0.05gm\L) (Figure 4), but it didn't reach
the significant level (P > 0.05), so no significant
differences was found in saliva caeruloplasmin
between RA patients and healthy controls.
Uric acid: The results showed that the mean of
serum uric acid in RApatients was (6.1mg\dl)
which was significantly higher (P < 0.001) than
that of the healthy controls(3mg\dl), it has been
shown that the mean of saliva uric acid in RA
patients(5mg\dl) was also significantly higher (P
< 0.001) than that of the healthy controls
(1.9mg\dl) (figure 5).
Table 1: Distribution of the study samples
according to gender and age.
Rheumatoid
Healthy Control
arthritis patients
N % N %
Gender
Female 16 64 39 76.5
Male 9 36 12 23.5
Total 25 100 51 100
Age in years
Range 20-60 17-65
Mean 36.4 40.4
S.D. 11.8 14.9
Oral Diagnosis
The study of oral manifestations
Table 2: Distribution of RA patients accord
to clinical disease activity index.
Disease Activity No. %
Inactive (remission) 5 9.8
Mild (low disease activity) 18 35.3
Moderate disease activity 15 29.4
Sever disease activity 13 25.5
Total 51 100
DISCUSSION
Age and Gender: In the present study the mean
age of RA patients was 40.4± 14.9 years and the
age range was 17-65 years. The number of female
RA patients was higher than male RA patients,
76.5% of RA patients were females and 23.5%
were males which were agreed with other studies
(10-11)
. Rheumatoid arthritis is a chronic,
progressive multisystemic inflammatory disorder
with a prevalence of approximately 0.5-1%. It
usually involves middle aged adults with a
females being affected more than males (12).
CDAI: The results showed that the number of RA
patients with mild disease activity according to
the CDAI was significantly higher. Joint damage
begins early in the course of the disease as a
consequence of the active inflammation, and can
lead to progressive and irreversible disability. To
allow physicians to evaluate the indication and
effect of particular therapies, accurate assessment
of disease activity is necessary.. Some of these
(and additional) measures are used in composite
indices to assess disease activity or a disease
activity state at any point in time and can inform
the physician (and patient) about improvement (or
deterioration) in disease activity from or states at
a particular level at baseline, to that seen at any
specific time point. The accurate assessment of
disease is, therefore, an important part of the care
of patients with RA (13).
Salivary flow rate: It has been found that saliva
flow rate was significantly higher in the healthy
controls than in the RA patients. The reduction in
salivary gland function as measured by saliva
flow rate in the RA patients result from that the
salivary glands are major target organs of RA.
Oral manifestations: Xerostomia was the
important oral manifestations of the RA patients
which was present in 49% of those patients. It was
shown as a decrease in saliva flow rate. The
results of the present study also showed that the
percentage of RA patients with xerostomia was
higher in the newly diagnosed patients than in the
old diagnosed patients this is may be due to the
effect and benefit of methotrexate treatment in
those patients. Angular cheilitis and candidal
76
J Bagh College Dentistry
infection was found in 29.4% of RA patients and
it was found to be higher in old diagnosed patients
(on methotrexate treatment) which were found in
30% of those patients. Patients with rheumatoid
arthritis (RA) have been shown to have an
increased susceptibility to the development of
infections. The exact causes of this increased risk
are unknown, but may relate to immunologic
disturbances associated with the disease or to the
immunosuppressive effects of agents used in its
treatment.Oral candidiasis that are presented in
RA patients on methotrexate may be due to the
use of immunosupressive drugs or to lower
salivary flow rates that usually affect RA
patients.Oral ulceration was also found in 29.4%
of RA patients and was higher in the old
diagnosed RA patients (patients on MTX
treatment) which were found in 33.3%,
Serum and saliva MDA: In the presented study it
has been shown that serum and saliva MDA were
significantly higher in RA patients than in the
healthy controls, this results was agreed with the
results of other studies (10-14).
Serum and saliva Caeruloplasmin: CP is a highly
significant event in the course of rheumatic
disease such as rheumatoid arthritis, ankylosing
spondylitis and systemic sclerosis. There is a
significant correlation between serum levels of CP
and disease activity in RA patients.
Serum and saliva uric acid: It has been shown that
serum and saliva UA were significantly increased
in RA patient than in the control subjects (10).
REFERENCES
1- Van den Berg WB. Joint inflammation and
cartilage destruction may occure uncoupled.
Springer. Semin Immunopathol 1998; 20:149-164.
2- Harris ED, Budd RC, Genovese MC, Firestein
GS, Sargent JS eds. Kelley's Textbook of
Rheumatology. 7th ed. Philadelphia, Pa: Saunders
Elsevier; 2005.
3- Alamanos Y, Voulgari PV, Drosos AA
Incidence and prevalence of rheumatoid arthritis,
0.9
0.8
0.7
Flow rate (mL/min) .
0.6
0.5
0.4
0.3
0.2
0.1
0
Healthy Controls
Figure 1: Saliva flow rate in healthy control and RA patients.
Oral Diagnosis
Vol. 23(3), 2011 The study of oral manifestations
based on the 1987 American College of
Rheumatology criteria: a systematic review. Semin
Arthritis Rheum 2006; 36 (3): 182–8.
4- Arnett F, Edworthy S, Bloch D, McShane D,
Fries J, Cooper N, Healey L, Kaplan S, Liang M,
Luthra H. The American Rheumatism Association
1987 revised criteria for the classification of
rheumatoid arthritis. Arthritis Rheum1988; 31 (3):
315–24.
5- Saag KG, Gim GT, Nivedita M et al. American
College of Rheumatology 2008 Recommendations
for the Use of Nonbiologic and Biologic Disease-
Modifying Antirheumatic Drugs in Rheumatoid
Arthritis. Arthritis & Rheumatism 2008; 59 (6):
762–784.
6- Pisetsky DS, St Clair EW Progress in the
treatment of rheumatoid arthritis. JAMA 2001;
286(22):2787-2790.
7- Pedrazas CHS, de Azevedo MNL, Torres SR.
Oral events related to low-dose methotrexate in
rheumatoid arthritis patients. Braz Oral Res 2010; 24
(3):368-73.
8- Sies H. Oxidative stress: oxidants and
antioxidants. Exp Physiol 1997; 82 (2): 291–5.
9- Mapp Pl, Grootveld Mc. Hypoxia, oxidative
stress and rheumatoid arthritis. Br Med Bull 1995;
51(2):419-36.
10- Nagler RM, Salameh F, Reznick AZ, Livshits V,
Nahir AM. Salivary gland involvement in
rheumatoid arthritis and its relationship to induced
oxidative stress. Rheumatology2003; 42:1234-1241.
11- Pallinti V, Nalini G, Chegu H, Rajasekhar G,
Meera S. Plasma lipophilic antioxidant and pro-
oxidant levels in rheumatoid arthritis. J Indian
Rheumatol Assoc 2004; 12:40-2.
12- Cush, JJ. Rheumatoid arthritis, clinical symposia
by Novartis 1999; 51: 1.
13- Smolen JS, Aletaha D. The assessment of
disease activity in rheumatoid arthritis. Division of
Rheumatology, Medical University of Vienna, and
Hietzing Hospital, Vienna, Austria. Clin Exp
Rheumatol 2010; 28(3 Supple 59):S18-27.
14- Pullaiah A, Vani N. Oxidative Stress and
Calcium Phosphorus Ratio in Rheumatoid Arthritis.
Indian J Clinic Biochem supplements 2009; 275.
0.8
0.4
GroupsRA patients
77
J Bagh College Dentistry Vol. 23(3), 2011 The study of oral manifestations

Figure 2: Oral manifestations and TMJ disorders

Figure 3: The mean of serum and saliva MDA in healthy controls and RA patients.

Figure 4: The mean of serum and saliva ceruloplasmin in healthy control and RA patients

Oral Diagnosis 78
J Bagh College Dentistry Vol. 23(3), 2011 The study of oral manifestations

Figure 5: The mean of serum and saliva uric acid in healthy control and RA patients

Oral Diagnosis 79
J Bagh College Dentistry Vol. 23(3), 2011 Factors associated with parotid

Factors associated with parotid gland enlargement among

poorly controlled Type II Diabetes Mellitus
Zainab H. AL-Ghurabi B.D.S, M.Sc (¹)
Ahlam A. Fatah B.D.S, M.Sc (²)
Omar F. NAFEA MBChB, C.A.B.M (³)
Warda L. Sleman DGO (4)
Qusay A. Fahad MBChB, D.M.R.D, F.I.B.M.S (5)

ABSTRACT
Background: Microscopic examination of parotid gland reveals hypertrophy of the aciner cells sometimes two to
three times greater than normal size of PG, in cases associated with longstanding diabetes. This study was designed
to determine the effects of duration, fasting plasma glucose and glycosylated hemoglobin on parotid gland
enlargement among poorly controlled type 2 diabetes mellitus.
Subjects, Materials, and Method: This study was conducted on 36 parotid glands of 18 with type 2 DM , at age range
( 40-60) years, all of them were selected from subjects attending (Endocrine clinic for diabetic patients) in Baghdad
Teaching Hospital. , pg was measured with ultrasonography in both longitudinal and horizontal plane.
Results: the rate of enlargement of pg was higher with higher duration period of DM study sample , also the rate of
enlargement of pg was higher with higher value of HbA1c % and finally the rate of enlargement of pg was higher
with higher fasting serum glucose level among DM study group.
Conclusion: This result show that the duration is the most effective factor associated with parotid gland enlargement
among poorly controlled type 2 DM.
Key words: Diabetes mellitus, duration, fasting plasma glucose, glycosylated hemoglobin. (J Bagh Coll Dentistry
2011;23(3): 80-82).

INTRODUCTION SUBJECTS, MATERIALS, AND

Duration of disease, and degree of metabolic
controls play an important role in oral
complications and salivary gland involvement of
diabetes rather than whether the types of disease
was type 1DM or type 2 DM (1),(2). In cases
associated with long duration DM there may be
aciner atrophy and fatty infiltration associated
with sialadenosis(3),(4) .
The onset and progression of the complication in
DM was strongly linked to the presence of
sustained hyperglycemia, while the complication
rate and the severity of the complications
increased as the duration of the disease increases
(5),(6)
.The enlargement of PG and xerostomia can
occur with DM and both of them may be related
to the metabolic control which come in
conformity with our result(7).
METHOD
This study was conducted on 36 parotid glands of
18 females with type 2 DM , at age range ( 40-60)
years, all of them were selected from subjects
attending (Endocrine clinic for diabetic patients)
in Baghdad Teaching Hospital. The body weight,
subject must not exceeded 20% from the Ideal
Body Weight(IBW), according Broca's formula
IBW=height-100)(8). Ultrasonography with 7.5
MHz probe was used to measure the parotid gland
in longitudinal plane to measure the length of
gland and horizontal plane to measure
anteroposterior dimension of the gland.

(1) Assist. Lecturer, college of dentistry, univ. of Baghdad.

(2) Assist. Professor, college of dentistry, univ. of Baghdad.
(3) Lecturer, college of dentistry, univ. of Baghdad.
(4) Medical sinologist, MOH.
(5) Medical radiologist, MOH.
Figure 1: Longitudinal plane of probe.

Oral Diagnosis 80
J Bagh College Dentistry Vol. 23(3), 2011
Figure 2: Transverse plane of probe
Assessment of type 2 DM poorly controlled
patients:
1-Fasting plasma glucose (FPG) test: This test
was done in (Baghdad Teaching Hospital
laboratory) for study group and also done for
control group to ensure that all subjects in control
group were free from this disease. According to
American Diabetic Association(9) , FPG reveals
that glucose level for healthy subjects was
between 60-110mg/dl, while for patients with DM
was 126 mg/dl and over.
2- Glycosylated hemoglobin A1c test (HbA1c):
This test was done in (Teaching Laboratories) for
study group to assess the controlling of patients
for this disease. This test showed that for optimal
diabetic control HbA1c value not great than 7%
and until 7.9% consider a moderate or acceptable
control, while from 8% - 9.5% represent poor
control DM patients
RESULT
The rate of enlarged parotid gland increase with
increasing of associated factors significantly.
Table 1: The rate of enlarged parotid gland by selected independent variables among DM cases.
Total Enlarged Parotid gland P (Chi-square)
N N
1. Duration of DM (years)-tertiles
Lowest (first) tertile (<= 7.0) 14
Middle (second) tertile (7.1 - 14.0) 12
Highest (third) tertile (14.1+) 10
2. HbA1c %-tertiles
Lowest (first) tertile (<= 8.2) 14
Middle (second) tertile (8.3 - 8.8) 12
Highest (third) tertile (8.9+) 10
3. Fasting serum glucose (mg/dl)-tertiles
Lowest (first) tertile (<= 250) 14
Middle (second) tertile (251 - 370) 12
Highest (third) tertile (371+) 10
4 Age group (years)
40-49 16
50-60 20
Oral Diagnosis 81
Factors associated with parotid
A higher duration of disease was significantly
associated with a high rate of parotid enlargement.
The rate increase from 0% for those with lowest
duration to 90% for those with higher duration.
A higher HBA1c% was significantly associated
with a high rate of parotid enlargement. The rate
increase from 30.8% for those with lowest
duration to 80% for those with higher. HBA1c%
A higher serum fasting glucose was significantly
associated with a high rate of parotid enlargement.
The rate increase from 16.7% for those with
lowest duration to 81.8% for those with higher
fasting serum glucose .
A higher age group was significantly associated
with a high rate of parotid enlargement. The rate
increase from 20% for those with lowest duration
to 65% for those with higher old age.
DISCUSSION
Our result were very close to those obtained by
Coleman in 1998 (6), similar finding of Richard et
al and Carda (7,8), who stated that, duration of
disease and degree of metabolic controls play an
important role in oral complications and salivary
gland involvement of diabetes rather than whether
types of disease was type 1 or type 2 DM.
Mealey (9) stated that, the onset and progression
of the complication in DM was strongly linked to
the presence of sustained hyperglycemia, while
the complication rate and the severity of the
complications increased as the duration of the
disease increases.
Sreebny et al (10) found that, the enlargement of
parotid gland and xerostomia can occur with DM
and both of them may be related to the metabolic
control b which come in conformity with our
result.
%
0 0 <0.001
6 50
10 90.9
4 30.8 0.001
4 33.3
8 80
4 16.7 <0.001
4 41.7
8 81.8
4 20 <0.001
12 65
J Bagh College Dentistry Vol. 23(3), 2011
Figure 3: Bar chart showing the rate of enlarged parotid gland by selected independent variable
among DM cases.
REFERENCES
1. Holsinger EC and Bui DT. Anatomy, function
and evaluation of the salivary gland. In: Myers
EN and Ferris RL. Salivary gland disorder.
BrlinHeildbeg new York.spriger 2007. p 2-3.
2. Nevile BW, DammDD, Allen CM and Bouqnot
JE. Oral and Maxillofacial pathology 3rd edition.
Philad. Saunders Co. 2009 p 470-471.
3. Chandra S, Chandra S, Chandra G and Kalmaa
R. Oral Medicine. New Delhi: Japee brothers
medical publishers 2007 p 187-90.
4. Hausegger K W, Krasa H, Plezmann W, Grasser
R K, Frisch C and Simon H. Sonogrphie der
spichelderusen. Ultraschall Med 1993;14:68-74.
5. American Diabetes association. Revises
Diabetes Guideline. Diabetes Care 2009; 32:1-5.
Oral Diagnosis
Factors associated with parotid
6. Coleman H, Altini M, Nayler S, Richards A.
Sialoadenosis: a presenting sign of bulimia.
Head & Neck 1998; 20:758–62.
7. Richard, Hlousek L, Doyle A. Oral
Manifestations of Systemic Diseases. New
Jersey Dental School 1998; 65:309-15.
8. Carda C, Lioreda NM, Salom, Ferraris MEG,
Pyder A. Structural and functional salivary
disorder in type2 in diabetic patients. Med. Oral.
Patho Oral Cir Bucal 2006; 11(4).
9. Mealey B. Diabetes Mellitus. IN: GreenBerg MS
and Glick M. Burckt's Oral Medicine.
Philadelphia: BC Decker Inc. 2003 ; 567
10. Sreebny LM, Yu A, Green A, Valdini A.
Xerostomia in diabetes mellitus. Diabetes Care
1992;15:900–4
82
J Bagh College Dentistry Vol. 23(3), 2011 Salivary enzymes as markers

Salivary enzymes as markers of chronic periodontitis

among smokers and non smokers
Ayser N. Mohammad B.D.S, M.Sc (1)

ABSTRACT
Background: the periodontal cells contain many intra cellular enzymes like alanine aminotransferase (ALT). asparate
aminotransferase (AST), and lactate dehydrogenates (LDH) that are released outside into the saliva and gingival
crivicular fluid (GCF) after destruction of periodontal tissue during periodontitis.
Aim of the study: To determine the activity of these enzymes in saliva among smoker and non smoker patients with
chronic periodontitis, and its relation to the clinical periodontal parameters (plaque index PLI, gingival index GI,
pocket depth PD and clinical attachment level CAL).
Material & methods: 40 samples of chronic periodontitis patients (20) non smokers and (20) smokers were collected
for the study of salivary (AST), (ALT), and (LDH) levels were analyzed spectra metrically.
Result: statistical analysis revealed highly significant difference in LDH activity (142±14.63IU/L) between smoker and
non smoker groups with significant positive correlation between the activity of LDH and GI, PD and CAL among
smokers. Also significant positive correlation between AST, ALT, LDH enzymes and CAL in smokers.
Conclusion: The present study showed a significant positive correlation between CAL and all enzymes levels among
smokers.
Key words: non smokers, smokers, salivary enzymes, periodontitis. (J Bagh Coll Dentistry 2011;23(3): 83-87).

So the response of an organism to the

INTRODUCTION
Periodontal disease is one of the common
inflammatory disease within complex etiology
and multifactorial in origin. Diagnosis of
periodontal disease has been primarily based
upon clinical and radiographic measures of
periodontal tissue destruction. These parameters
provide measures of past destruction and are
limited use in early diagnosis (1).
New diagnostic tools based on body fluids
such as saliva and gingival circular fluid (GCF),
as well as studies of sub gingival micro flora and
genetic susceptibility, are useful and should be
further developed(2).
Saliva is an important biological material that
introduces new diagnostic tests, which may
contribute in the diagnosis and explaining the
pathogenesis of many diseases (3).
Intracellular enzymes such as ALT, AST, and
LDH are increasingly released from the damaged
cells of periodontal tissue into the GCF and
saliva (4).
Such AST, ALT and LDH enzymes can help
to monitor the progression of periodontal disease
and they appear to be useful to test the activity of
periodontal disease (5).
Enzymes are present in much higher
concentration inside than outside the cells are
released as a result of necrosis or sever damage
to the cells caused by ischemia or toxin. Also the
increased rate of cell turn over during active
growth or tissue repair may cause increase
enzymes level inside the cells.
(1)
Lecturer, Department of Periodontics, College of
Dentistry, University of Baghdad
periodontal infection includes production of
several enzyme families which are released from
stromal, epithelial, inflammatory and bacterial
cells. The analysis of these enzymes in salivary
secretion can contribute to the clarification of
pathogenesis and to improvement of making a
prompt diagnosis of the periodontal diseases (6).
Alanine aminotransferase and AST enzymes
are found in the cytoplasm of the cells and its
increased extracellular level is caused by cell
member lyses after necrosis. These cells release
AST and ALT into the extracellular space during
periods of periodontal tissue destruction (7).
Higher levels of ALT and AST are found in
the GCF and diseased site, than healthy sites.
Also significant ALT and AST level have been
found in human gingival epithetical cells, human
gingival fibroblasts and human periodontal
ligament fibroblast (8). Highly significant
differences in the enzymatic activity of AST &
ALT have been found between healthy and
chronic periodontitis patients (9).
Within the cells glucose is used principally
for the production of pyruvate in the glucolysis
pathway, under aerobic condition, pyruvate enter
the mitochondrial matrix, where it is oxidized by
the action of pyruvate dehydrogenase, being
transformed into acetyl –CoA which still under
aerobic conditions, subsequently enters the citric
acid cycle. In an anaerobic media, pyruvate is
reduced to lactate in a reversible reaction
catalyzed by lactate dehydrogenates, which use
nicotinamide adenine dinucleotide as coenzyme
(10)
.So LDH is an enzyme in the cytoplasm in
almost every cell of human body, which
becomes extracellular presence always related to

Oral and Maxillofacial Surgery and Periodontology 83

J Bagh College Dentistry Vol. 23(3), 2011 Salivary enzymes as markers

cell necrosis, and tissue break down (11). Lactate mid-buccal, disto-buccal, mesio-lingual, mid-
dehydrogenates activity provides information on lingual and disto-lingual were detected excluding
cellular glycolitic capacity. .Measurement of third molars.
LDH release (Leakage) is an important and The probe was directed parallel to the long
frequently applied test for cellular member axis of the tooth. The pocket depth
permeabilization and severs irreversible cell measurements in mm were grouped and scaled
damage (12, 13). from (0-3) as shown in table 1.
Although gingival inflammation in smokers Table 1: Scale of PD measurements
appears to be reduced in response to plaque
Scale 0 1 2 3
accumulation when compared with non smokers,
an over whelming body of data point to smoking PD in (mm) 1-3 4-5 6-7 ≥8
as a major risk factor for increasing the
prevalence and severity of periodontal Clinical attachment level was obtained by
destruction (14). measuring the distance from the cemento-enamel
Many studies have demonstrated that pocket junction to the bottom of the pocket at each site.
depth, clinical attachment loss, and alveolar bone The CAL measurement in (mm) were
loss are more prevalent and sever in patients who grouped and scaled from (1-4) as shown in Table
smokes compared with non smokers (15, 16). 2. (20)
The increased prevalence and severity of
periodontal destruction associated with smoking Table 2: Scale of CAL measurements
suggests that the host bacterial inter action
Scale 1 2 3 4
normally seen in chronic periodontitis are altered
result in more aggressive periodontal break CAL in (mm) 1-3 4-5 6-7 ≥8
down. This imbalance between bacterial
challenge and host response may be due to
The unstimulated mixed saliva was collected into
changes in composition of the sub gingival
polyethylene tube & stored at (-20°) in freezer
plaque with increases in the numbers and/or
until analyzed. The activity of AST, ALT and
virulence of the pathogenic organisms; changes
LDH in saliva was determined spectra metrically
the host response to the bacterial challenges or
by the standard of the international factration of
combination of both (17).
the clinical chemistry method with specific
The aim of this study is to determine the
reagents. (21)
activity of these enzymes in saliva among
smokers and non smoker’s patients with chronic
periodontitis, and its relation to the clinical RESULTS
periodontal parameters. Table 3 shows a description of PLI and GI
findings of both smoker and non smoker groups.
The mean PLI for smoker group was (2.353 ±
MATERIAL AND METHODS 0.632); while for the non smoker group it was
Forty chronic periodontitis patients. 20 of
(2.332 ± 0.498).
them were smokers and 20 were non smokers,
The mean GI of smoker group was (1.227 ±
with no history of any systemic disease, age
0.218), while the mean GI for non smokers was
range 30-57 years attending Department of
higher than the smoker group (2.005 ± 0.406)
Periodontics, Collage of Dentistry, University of
(Table 3).
Baghdad were selected for this study.
In Table 4, statistical analysis comparing
All participants had chronic periodontitis.
between PLI of the smoker group with PLI of
They have no medical condition that would
non smoker group showed no significant
affect their participation in the study, no history
differences, while highly significant difference
of regular use of mouth washes, use of any
was found between GI for smoker and non
vitamins supplementation or mucosal lesions,
smokers (P value < 0. 01).
chemotherapy, radiation therapy, or any
Table 5 shows a scale of PD measure
condition cause xerostomia. Patient was regarded
representing the number of sites for each score
as a smoker, if regularly smoked at least 10
and their percentage. For the smoker group
cigarettes on average per day, for the last five
(22.96%) of the sites had score 0, (37, 8%) had
years (18). While the non smokers, i.e. who had
score1, (27.2%) had score 2 and (12, 04%) had
never smoked tobacco. Clinical periodontal
score 3, while for the non smoker group (83.3%)
parameters such as PLI, GI (19), PD and CAL.
of sites had score 0, (8.7%) had score 1 (5.2%)
were determined using William’s periodontal
had score 2 and (2.8%) of sites had score 3. Chi-
prob. Six sites around each tooth (mesio-buccal,

Oral and Maxillofacial Surgery and Periodontology 84

J Bagh College Dentistry Vol. 23(3), 2011
square applied to test the significance of % PD
between two groups was 5.99, with p-value
0,0112 (significant).
For CAL (Table 6) showed that (4, 57%) of
the smoker group had score 1, (59, 14%) had
score 2, (26.6%) had score 3 and (9.67%) had
score 4; while for the non smoker group (86.3%)
had score 1, (7.28%) had score 2, (5.01%) had
score 3 and finally (1.4%) had score 4. Chi-
square applied to test the significance of % CAL
between the two groups was 5.334, with p-value
0,014 (significant).
The mean salivary AST level in smoker and
non smoker groups were 23 ± 15.57 IU/L and
38.7 ± 17.75 IU /L respectively, while the mean
ALT in smokers and non smokers were 26.4 ±
0.68 IU/L and26.4 ± o.94 IU/L respectively
(Table 7).
The mean of the enzyme level LDH in
smoker group (142 ± 14.63 IU/L) was increased
in comparison with the non smoker group (79.
45 ± 8.61 IU/L) (Table 7).
Using student t-test (Table8) showed highly
significant variation between the levels of
LDH in smoker when compared with its level in
the non smoker group (P value <0.01).
Table 9 using spearman showed positive
correlation between the periodontal parameter’s
and salivary enzymes. Significant positive
correlation between PLI, CAL and AST in
smokers, also significant correlation between
LDH and CAL in smokers compared to non
smokers. This study showed a significant
positive correlation between the activity of all
enzymes AST, ALT, and LDH and CAL in
smoker group.
DISCUSSION
The mean of PLI for smoker and non smoker
groups, were (2.353, 2.332) respectively. This
was due to sample selection in which both
groups had chronic periodontitis with poor oral
hygiene.
In this study, there was highly significant
difference in GI finding between smoker and non
smoker groups. The mean of GI for the smokers
was (1.227 ±0.218), while for the non smokers
was (2, 005± 0.406). This could be due to the
effect of smoking on the gingival tissue causing
superficial vasoconstriction leading to the
reduction of the gingival inflammation for the
smoker patients. These results agreed with
Vander et al (22).
The smoker group had (12.04%) PD score 3
and (26.6%) CAL score 3 with significant
different compared to non smokers. The increase
in the severity of PD and CAL among smoker
Oral and Maxillofacial Surgery and Periodontology 85
Salivary enzymes as markers
patients was due to increase prevalence and
severity of periodontal destruction. These results
are in consistent with Ray et al. (23)
From the results of this study, no significant
difference for AST and ALT enzymes levels in
the saliva between smokers and non smokers
these results disagree with Vander et al and Ray
et al (22, 23). This could be due to the number of
sample selected and different methodology.
The mean LDH level in the smoker group
was (142 ± 14.63 IU/L), while for the non
smoker group was (79, 45 ± 8.61 IU/L).This
high level activity in saliva is a consequence of
their increase released from the damaged cells of
soft tissue and severe periodontal destruction
represented in deep pockets and bone loss among
smokers . This finding was in accordance with
other studies done by Ray and Todorovc et al
(23, 24).
In the present study statistical analysis in
table 9 indicated the presence of a non
significant correlation between AST, ALT, LDH
and PLI, in both groups except for AST in the
smoker group. These findings agree with
Herasaki et al (25).
Significant positive correlation between GI,
PD and LDH in both groups. This result is in
agreement with Todorovic et al (24).
The present study showed a significant
positive correlation between CAL and all
enzymes levels among smokers reflecting the
biological activity that take place in the
periodontium during acute and chronic
inflammatory response. This result agrees with
Ray et al (23).
REFERENCES
1. Haffajee AD, Soransky SS, Goodson JM.
Clinical parameters of predictors of destructive
periodontal disease activity. J Clinic Periodontol 1983;
10: 257-65.
2. Armitage GC. Diagnosis of periodontal
diseases [published erratum appear in J periodontol
(2004); 75: 779]. J Periodontol 2003; 74: 1237-1247.
3. Malamud D. Saliva as a diagnostic fluid. Br
Med J 1992; 305: 207-18.
4. Kaufman E and Lamster IB .Analysis of saliva
for periodontal diagnosis. J Clinic Periodontol 2000; 27:
453-465.
5. Ozmeric N. Advances in periodontal disease
markers. Clinic Chim Acta 2004; 345: 1-16.
6. Moss DW, Henderson AR. Clinical
enzymotologyIn: Burtic Ca. Ash wood Er. Editors. Tietz
textbook of clinical chemistry. 3rd edition. Philadelphia:
Saunders 1999; 617-721.
7. Williams, D Land Marks V. Biochemistry in
clinical practice William Heinemann Medical Books.
London 1983. P: 142-149.
8. Emilio BS, Sergio LS. Use of Asparate amino
transferase in diagnosing periodontal disease: a
J Bagh College Dentistry Vol. 23(3), 2011
comparative study of clinical and microbiological
parameters. J Oral Science 2003; 45: 33-38.
9. Mustafa JA .Evaluation of salivary enzymes
activity among patients with chronic periodontitis.
[Master thesis] Department of Periodontics. College of
dentistry, University of Baghdad; 2009.
10. Nomura Y, Tamaki U, Tanaka T, Arakawa H,
Tsurumoto A .Screening of periodontitis with salivary
enzyme, J Oral Science 2006; 48 (4): 177-83.
11. Eely BM and Cox SW. Advances in
periodontal diagnosis, potential markers of cell death &
tissue degradation. Brit Dent J 1998; 184: 427-430.
12. Renner AD. changes of mitochondrial
respiration, mitochdrial content and cell size after
induction of apoptosis in leukemia cells. Biochim.
Biophys. Acta Odontol 2003; 1642: 115-123.
13. Bergmeier HU Method end enzymatischen
analysis. 2. Auflage, AkadeuicVerlage Berli (1970)
14. Carranza FA .Clinical periodontology 9th
edition Philadelphia. WB saunters company; 2002.245-6.
15. Reatmans .Tobacco use and the periodontal
patient. J periodontol 1999; 70: 1419.
16. Tonetti MS. Cigarette smoking and periodontal
disease: etiology and management of disease. Ann
Periodontol 1998; 3: 88.
17. Stoltenberg JL, Osborn JB, et al. Association
between cigarette smoking, bacterial pathogen and
periodontal statues. J periodontol 2001; 64: 1225.
18. Scabbia A, Cho K, Singurdsson T. Cigarette
smoking negatively affects healing following flab
debridement surgery. J Periodntol 2001; 72: 43-49.
Oral and Maxillofacial Surgery and Periodontology 86
Salivary enzymes as markers
19. Silness J, Löe H. Periodontal disease in
pregnancy. Acta Odontl Scand 1964; 22:121-35.
20. Aboud LH. The periodontal health status of
postmenopausal women. (Master thesis) Department of
Periodontics,Collage of Dentistry, University of Baghdad
2004.
21. Yeashie Yl. Salivary enzyme level after scaling
and inter leukin-1 Genotypes in Japanese patients with
chronic periodontitis. J periodontol 2007; 78: 498-503.
22. Vander W, Kharbs S and Anand SC
.Periodontitis in smokers and non smokers: intraoral
distribution of pockets. J Clinic Periodontol 2001; 28:
955-60.
23. Ray Al, Dozic I,Vincen BM ,Ljuskovic
B,Pejovic J,and Knezevic M. Salivary Enzymes and
Thiocynate: Salivary markers of periodontitis among
smokers and non smokers; pilot study. Advances in
Medical and Dental Sciences 2007; 1:1-4.
24. Todorovic T,Yamazaki T,and Shipa K.
Salivary enzymes and periodontal disease. Med oral Path
oral Cir Bucal 2006; 11: 115-119.
25. Herasaki S, et al. Changes in salivary
component by drug administration in patients with heart
diseases. J Med Sci 2005; 52: 183-188.
J Bagh College Dentistry Vol. 23(3), 2011 Salivary enzymes as markers

Table 3: Statistical description of PLI and GI (Mean, SD) for both groups
Smoker Non smoker
PLI GI PLI GI
Mean ± SD 2.353±0.632 1.227±0.218 2.332±0.498 2.005±0.406

Table 4: t-test between smoker and non smoker of PLI, GI

t-test P-value Sig
PLI 0.134 0.895 NS
GI 7.61 0.00** HS
**P<0.01 High significant

Table 5: A scale of PD measurement showing the number of sites in each score and their percentage
in both groups
0 1 2 3
No 1707 144 99 27
smoker
% 22,96 37,8 27,2 12,04
No 1695 176 107 57
Non-smoker
% 83,3 8,7 5,2 2,8
Chi-square 5.99, P-value 0.0112 significant

Table6: A scale of CAL measurement showing the number of sites in each score and their percentage
in both groups
1 2 3 4
No 17 220 99 36
smoker
% 4,57 59,14 26,6 9,67
No 124 204 147 65
Non-smoker
% 86,3 7,28 5,01 1,4
Chi-square 5.334, P-value 0.014 significant

Table 7: Statistical description (mean level in IU/l, SD) of AST, ALT, and LDH in both groups
AST ALT LDH
Smoker Mean ± SD 32±15,57 26,4±0,68 142±14,63
Non- smoker Mean ±SD 38,7±17,75 26,4±0,94 79,45±8,61

Table 8: t-test of mean AST, ALT and LDH levels in the smokers in comparison to non smokers
t-test P-value Sig
AST 1.309 0.206 NS
ALT 0.00 1.00 NS
LDH 16.389 0.00** HS
P>0.05 Non significant **P<0.01 High significant

Table 9: Spearman correlation (r) of AST, ALT, and LDH levels with PLI, GI, PD and CAL in both
groups
AST ALT LDH
PLI 0.307* 0.132 0.221
smoker

GI 0.286 0.275 0.309 *

PD 0.172 0.26 0.49 *
CAL 0.347* 0.53 * 0.438 *
PLI 0.135 0.279 0.128
smoker

GI 0.271 0.160 0.307 *

Non

PD 0.308 * 0.222 0.49 *

CAL 0.235 0.161 0.120
*P<0.05 significant

Oral and Maxillofacial Surgery and Periodontology 87

J Bagh College Dentistry Vol. 23(3), 2011 Experimental gingivitis

Experimental gingivitis in overweight subjects

Clinical and Microbiological study
Hadeel M. Abbood Salman B.D.S. (1)
Abdullatif A. Al-juboory B.D.S., M.Sc., Ph.D. (2)

ABSTRACT
Background: Obesity is a complex multifactorial chronic diseasethat affecting the host immunity which may stimulate
a hyperinflammatory response in periodontal disease. The aim of the study is to determine and compare the gingival
clinical parameters between Obese, pre-obese, and normal weight. Along with estimating the effect of overweight
on healing process of experimental gingivitis, also to determine and compare the microbiological findings between
Obese, pre-obese, and normal weight.
Materials and Methods: Our study dealing with experimental gingivitis using the clinical parameters (plaque index
and gingival index), existent bacterial flora, oral hygiene improvement on normal weight, pre-obese, and obese
subjects showing healthy systemic condition, using the body mass index (BMI) and inter parametric comparison on 30
individuals, male with no previous medical history, age ranged from 20-30years old,10 of them are obese, 10 are
within overweight(pre-obese) and the other 10 are within normal weight.Dental plaque samples were taken from
each subjects when the gingiva reaches inflammation (Mean GI≥1).
Results: The G.I .parameter showed a significant higher score of inflammation on the pre-obese and obese samples
during the initiation of the disease (P≤0.002), and also showed a prolonged improvement response after the recovery
of the oral hygiene control (P≤0.001).The bacterial findings showed an equal percent of streptococci and
staphylococci but with predominance on other species in normal weight subjects. The pre-obese showed an
increase percent of klebsiella .The obese subjects showed insignificant differences and almost equal percent of
streptococci, staphylococci and pseudomonades with undetectable number of klebseila.
Conclusion: This study found that Obesity is an active risk factor for gingival and periodontal disease, and it’s playing
a role in elevating body response to dental plaque with increasing the healing period.
Key words: Obesity, experimental gingivitis, microbiology, healing period. (J Bagh Coll Dentistry 2011;23(3): 88-91).

INTRODUCTION
Periodontal disease is a chronic disease of the
oral cavity comprising a group of inflammatory
conditions affecting the supporting structures of
the dentition (1).
The impact of dental plaque biofilms on the
etiology of periodontal diseases has been studied
in detail. However, it is the paradoxical impact of
the susceptible host's inflammatory response to
the microbial challenge that ultimately leads to
the destruction of periodontal tissues and
subsequent tooth loss (2).
Periodontal diseases represent chronic
inflammatory responses to a bacterial challenge.
Although bacterial biofilms have been shown to
be necessary in the initiation of gingival
inflammation and subsequent destruction of
periodontal tissues (3), its presence alone explains
a relatively small proportion (i.e. 20–30%) of the
variance in disease expression (4). Based on an
established model of pathogenesis (5), the bacterial
biofilm alone is insufficient to explain disease
initiation and progression. Evidence suggests that
periodontal tissues destruction is mainly due to
the host’s inflammatory response to the bacterial
challenge (5).
(1) MSc student, department of periodontics, college of Dentistry,
Baghdad University.
(2) Professor, department of periodontics, college of dentistry,
Baghdad University
Obesity is the fastest growing health-related
problem in the world (6).
A common metabolic and nutritional disorder,
obesity is a complex multifactorial chronic
disease that develops from an interaction of
genotype and the environment (7).
The impact of obesity on health status has the
same outcome as twenty years of aging, and has
been indicated to exceed the impact of smoking or
alcohol abuse (8).
The first paper on the relationship between
obesity and periodontal disease was appeared in
1977 on rats, which are more likely to have
periodontal disease deteriorations (9).
In humans, firstly on Japanese adult in 1998,
(10)
a higher BMI was related to a greater
prevalence of periodontal disease in 241
apparently healthy adult age 20-59 years, using
BMI and body fat to assess obesity and the
community periodontal index (CPI). Subjects with
BMI >30 compared to subjects with a BMI <20
body fat was analyzed using dual – energy X-ray
absorptionometry found a 5% increase in body fat
correspond to a 30% increased risk of periodontal
disease in patients having normal level fasting
blood glucose and cholesterol (11)(12).
It has been suggested that obesity contributes
to an overall systemic inflammatory state through
its effect on metabolic and immune parameters,

Oral and Maxillofacial Surgery and Periodontology 88

J Bagh College Dentistry Vol. 23(3), 2011
thereby increasing susceptibility to periodontal
disease (13,14).
In recent years, the evidence linking obesity to
increased incidence and severity of periodontal
disease has grown (15).
In general, data indicate that increased body
mass index, waist circumference (abdominal
obesity), serum lipid levels and percentage of
subcutaneous body fat are associated with
increased risk for periodontitis. After adjusting for
confounding factors such as smoking, age and
systemic conditions, the risk association appears
to be linear. For instance, more bleeding on
probing, deeper periodontal pockets and more
bone loss were noticed in individuals with higher
indicators of obesity (16).
The most recent study provides what is
perhaps the most compelling evidence to date for
a significant association between obesity and
increased prevalence, severity and extent of
periodontal disease (17). Therefore it was decided
to conduct this study.
MATERIAL AND METHODS
Our study dealing with experimental
gingivitis uses the clinical parameters (plaque
index and gingival index), existent bacterial flora,
oral hygiene improvement on normal weight, pre-
obese, and obese subjects showing healthy
systemic condition, using the body mass index
(BMI) and inter parametric comparison.
The sample consist of 30 individuals, male
with no previous medical history, no diabetes, non
smoker, with age ranged from 20-30years old.
10 of them are obese, 10 are within
overweight(pre-obese) and the other 10 are within
normal weight.
The gingival parameters were indexed on the
case sheet form which was filled for each subject
of the three groups, dental plaque samples were
taken from each subjects when the gingiva
reaches inflammation (Mean GI≥1).
RESULTS
Statistical analysis comparing between the
PLI of the three groups (normal weight, pre-
obese, and obese) in the 1st week of experimental
gingivitis using fisher test revealed a significant
difference (P:≤ 0.007).
The same statistical analysis comparing between
the PLI of the three groups in the 2nd week of
experimental gingivitis using fisher test revealed a
non significant difference (P:≤ 0.204). Also one
week after oral hygiene re-establishment a
statistical analysis comparing between the PLI of
the three groups using fisher test revealed a non
significant difference (P:≤ 0.291)(Table -1).
Oral and Maxillofacial Surgery and Periodontology 89
Experimental gingivitis
Statistical analysis comparing between the GI
of the three groups (normal weight, pre-obese,
and obese) in the 1st week of experimental
gingivitis using fisher test revealed a significant
difference (P:≤ 0.000).
The same statistical analysis comparing
between the GI of the three groups in the 2nd week
of experimental gingivitis using fisher test
revealed a significant difference (P:≤ 0.002).
Also one week after oral hygiene re-
establishment a statistical analysis comparing
between the GI of the three groups using fisher
test revealed a significant difference (P:≤
0.000)(Table-2).
DISCUSSION
Our study dealing with experimental gingivitis
using the clinical parameters (plaque index and
gingival index), existent bacterial flora, oral
hygiene improvement on normal weight, pre-
obese, and obese subjects showing healthy
systemic condition, using the body mass index
(BMI) and inter parametric comparison. We found
a significant difference obtained between normal
weight subjects (BMI 21.08 )on those of pre-
obese( BMI 27.085 ) and obese subjects( BMI
32.384)of their plaque index in the 1st week of the
experiment which signifying that pre and obese
having the ability to develop plaque accumulation
easier and faster than normal subjects (P:≤ 0.007)
this is because the dietary habits and increasing in
the frequency of food eaten in addition to the type
of food which’s more sticky and containing more
sugar that affects the formation of dental plaque.
When the gingivitis is created the all three groups
showing an almost equal amount plaque
accumulation. (non significant differences) (P:≤
0.204).
That’s mean the length of the period after
dental plaque formed will not affect the amount .
The G.I .parameter showed a higher significant
score of inflammation on the pre-obese and obese
samples during the initiation of the disease (P: ≤
0.000) especially after the 1st week of the
beginning of the experiment, that’s mean the
overweight subjects will develop gingivitis more
faster than normal weight.
Almost all the obese subjects were developed
mild form of gingivitis after 7 days of the
experiment, this result was disagreed with L e et
al in 1965, in their experiment all the subjects did
not develop gingivitis in the first week, this may
be due to the effect of obesity on the
inflammatory response leading to increasing the
levels of some cytokines like: TNF-α, IL-1, IL-6,
and IL-8, all these cytokines will intensify the
inflammation in addition to the thickening of the
J Bagh College Dentistry Vol. 23(3), 2011
blood vessels and increase the level of PAI-1, all
these effects will accelerat gingivitis.
These results were agreed with wood N.
studies in 2003 that indicates that there is increase
in bleeding tendency of gingiva in relation to the
BMI.
During the 2nd week of the experiment the
differences remain significant between the three
groups(Normal weight, Pre-obese, and Obese),
this mean that in spite of the development of
gingivitis in all the subjects in the three groups
but the obese and pre-obese having higher GI than
normal weight(p:≤ 0.002), this mean that the
overweight will not affect the initiation of
gingivitis only but also has an effect on the
progression of the disease.
Overweight subjects showed a prolong
improvement response after the recovery of the
oral hygiene control (P:≤ 0.001), after one week
of oral hygiene re-establishment the overweight
subjects returns to the normal state gingiva but
within higher limits, this result could suggest a
negative interference of the obesity on the
gingival healing that’s maybe due to the injurious
effect of some adipokines, Bazari et al in 2007
suggests that obesity causing poor wound healing
and slowing the healing process.
A significant positive correlation of GI with
BMI, and PLI with BMI could suggest that
overweight increasing the risk to initiate gingivitis
and could interfere in the course of the disease
progression.
The bacterial finding showed an equal
percent of streptococci and staphylococci but with
predominance on other species in normal weight
subjects. The pre-obese showed an increase
percent of klebsiella and undetectable number of
pseudomonades. The obese subjects showed
insignificant differences and almost equal percent
of streptococci, staphylococci and
pseudomonades with undetectable number of
klebseila.
These differences in bacterial species and
presence or absence of species suggest that there
are differences in the dental plaque composition,
maybe due to changes in food habits between
normal weight and overweight.
REFERENCES
1. Armitage GC. Development of a classification
system for periodontal diseases and conditions. Ann
Periodontol 1999; 4: 1-6.
Oral and Maxillofacial Surgery and Periodontology 90
Experimental gingivitis
2. Page RC, Kornman KS. The pathogenesis of
humanperiodontitis: an introduction. Periodontol 2000
1997; 14:9–11.
3. Socransky SS, Haffajee AD. Periodontal
microbial ecology. Periodontol 2000 2005; 38: 135–87.
4. Grossi SG, Zambon JJ, Ho AW, Koch G,
Dunford RG, Machtei EE, Norderyd OM & Genco RJ.
Assessment of risk for periodontal disease. I. Risk
indicators for attachment loss. J of Periodontol 1994; 65:
260–7.
5. Offenbacher S. Periodontal diseases:
pathogenesis. Annals of Periodontology 1996; 1: 821–78.
6. Haenle MM, Brockmann SO, Kron M, Bertling
U, Mason RA, Steinbach G, and others. Overweight,
physical activity, tobacco and alcohol consumption in a
cross-sectional random sample of German adults. BMC
Public Health 2006; 6:233–7.
7. Dennison EM, Syddall HE, Aihie Sayer A,
Martin HJ, Cooper C; Hertfordshire Cohort Study Group.
Lipid profile, obesity and bone mineral density: the
Hertfordshire Cohort Study. QJM 2007; 100(5):297–303.
Epub 2007 Apr 19.
8. Al-Zahrani MS, Bissada NF, Borawskit EA.
Obesity and periodontal disease in young, middle-aged,
and older adults. J Periodontol 2003; 74: 610–5.
9. Perlstein MI, Bissada NF. Influence of obesity
and hypertension on the severity of periodontitis in rats.
Oral Surg Oral Med Oral Pathol 1977; 43: 707–19.
10. Saito T, Shimazaki Y, Sakamoto M. Obesity and
periodontitis [letter]. N Engl J Med 1998; 339: 482–3.
11. Saito T, Shimazaki Y. Metabolic disorders
related to obesity and periodontal disease. J
Periodontology 2000 2007; 43: 254–66.
12. Saito T, Shimazaki Y, Kiyohara Y, Kato I, Kubo
M, Iida M, Koga T. The severity of periodontal disease is
associated with the development of glucose intolerance in
nondiabetics: the Hisayama study. J Dent Res 2004; 83:
485–90.
13. Genco RJ, Grossi SG, Ho A, Nishimura F,
Murayama Y. A proposed model linking inflammation to
obesity, diabetes, and periodontal infections. J Periodontol
2005; 76(11 Suppl):2075–84.
14. Van Dyke TE. Inflammation and periodontal
disease: a reappraisal. J Periodontol 2008; 79(8
Suppl):1501–2.
15. Saito T, Shimazaki Y, Kiyohara Y, Kato I, Kubo
M, Lida M, Yamashita Y. Relationship between obesity,
glucose tolerance, and periodontal disease in Japanese
women: the hisayama study. J Perio Res 2005; 40(8): 346-
53.
16. Wood N, Johnson RB, Streckfus CF.
Comparison of body composition and periodontal disease
using nutritional assessment techniques: Third National
Health and Nutrition Examination Survey (NHANES III).
J Clin Periodontol 2003; 30: 321–7.
17. Khader YS., Bawadi HA., Haroun TF., Alomari
M., Tayyem RF. The association between periodontal
disease and obesity among adults in Jordan. J Clinical
Periodontol 2009; 36(1): 18-24.
J Bagh College Dentistry Vol. 23(3), 2011 Experimental gingivitis

Table 1: Fisher test of the PLI for the 3 groups during the experiment
Fisher
P-value S/NS
F-value
in the 1st week: 5.944 0.007 S
in the 2nd week 1.685 0.204 NS
one week after oral
1.293 0.291 NS
hygiene re-establishment

Table 2: Fisher test of the GI for the 3 groups during the experiment
Fisher
P-value S/NS
F-value
1st week 32.302 0 S
2nd week 8.111 0.002 S
one week after oral
11.019 0 S
hygiene re-establishment

Table 3: Coefficient of correlation for 3groups

1st week of 2nd week of One week after
0
experimental experimental oral hygiene re-
Baseline
gingivitis gingivitis establishment
PL
Normal -0.36867 -0.3987 0.059086 -0.15732
I
weight
GI -0.29245 -0.10967 0.136932 -0.07184
PL
0.825566 0.265602 0.242018 0.844686
Pre-obese I
GI -0.55136 0.331306 0.240016 0.019861
PL
0.581584 0.441098 0.6571 -0.18077
Obese I
GI -0.32462 0.429774 0.28405 0.331346

Oral and Maxillofacial Surgery and Periodontology 91

J Bagh College Dentistry Vol. 23(3), 2011 Prevalence of periodontal abscess

Prevalence of periodontal abscess among controlled and

uncontrolled type 2 diabetic patients (comparative study)
Hayder R. Abdulbaqi B.D.S., M.Sc. (1)

ABSTRACT
Background: The aim of this study is to compare the periodontal health status and prevalence of periodontal
abscess between controlled and uncontrolled type 2 diabetic patients.
Material and Methods: sixty four type 2 diabetic patients were enrolled in this study, thirty two patients were
controlled diabetic and the other thirty two patients were uncontrolled diabetic. The study was cross sectional and
the diabetic patients were selected regardless the periodontal health status and sex but adjusted according type 2
diabetic mellitus. Periodontal health examination include plaque index (PLI), gingival index (GI), probing pocket
depth (PPD) and teeth with periodontal abscess were recorded except third molar teeth were excluded.
Results: There was no significant difference in mean of plaque index and probing pocket depth but significant
difference in mean gingival index between both groups. There was a significant difference regarding periodontal
abscess per tooth between both groups with a frequency distribution showed that the lower anterior teeth were
most affected followed by the upper anterior teeth then the lower posterior teeth.
Conclusion: periodontal abscesses affect more uncontrolled type 2 diabetic patient than controlled. So it is
important to the diabetic patients to control their diabetic status to avoid such a decline in their periodontal health.
Key words: periodontal abscess, type 2 diabetic patient, periodontal health status, frequency distribution. (J Bagh
Coll Dentistry 2011;23(3): 92-96).

INTRODUCTION
Periodontium is the general term that
describes the tissues that surround and support
the tooth structure. The periodontal tissues
include the gums, the cementum, the periodontal
ligament and the alveolar bone (1). Among several
acute conditions that can occur in periodontal
tissues, the abscess deserves special attention.
Abscesses of the periodontium are localized
acute bacterial infections which are confined to
the tissues of the periodontium(1). Abscesses of
the periodontium have been classified primarily,
based on their anatomical locations in the
periodontal tissue.There are four types (2) of
abscesses which are associated with the
periodontal tissues:
1) a gingival abscess which is a localized,
purulent infection that involves the marginal
gingiva or the interdental papilla; 2) pericoronal
abscesses which are localized purulent infections
within the tissue surrounding the crown of a
partially erupted tooth; 3) combined periodontal/
endodontic abscesses are the localized,
circumscribed abscesses originating from either
the dental pulp or the periodontal tissues
surrounding the involved tooth root apex and/or
the apical periodontium and 4) periodontal
abscesses which are localized purulent infections
within the tissue which is adjacent to the
periodontal pocket that may lead to the
destruction of the periodontal ligaments and the
alveolar bone. These are also known as lateral
peridontal abscesses or parietal abscesses.
(1)Assistant Lecturer, Department of Periodontics, College of
Dentistry, University of Baghdad.
Among all the abscesses of the periodontium,
the periodontal abscess is the most important
one, which often represents the chronic and
refractory form of the disease (2). It is a
destructive process occurring in the
periodontium, resulting in localized collections
of pus, communicating with the oral cavity
through the gingival sulcus or other periodontal
sites and not arising from the tooth pulp.
The important characteristics of the
periodontal abscess include: a localized
accumulation of pus in the gingival wall of the
periodontal pockets; usually occurring on the
lateral aspect of the tooth; the appearance of
oedematous red and shiny gingiva; may have a
dome like appearance or may come to a distinct
point. Depending on the nature and course of the
periodontal abscess, an immediate attention is
required to relieve pain and systemic
complications (1).
Moreover, the presence of an abscess may
also modify the prognosis of the involved tooth
and in many cases, may be responsible for its
removal. Therefore, accurate diagnosis and the
immediate treatment of the abscesses are the
important steps in the management of patients
presenting with such abscesses. The prevalence
of periodontal abscess is relatively high, which is
often the reason why a person seeks dental care
(1)
. Periodontal abscess accounts for 6% - 14% of
all dental emergencies (3). It is the third most
common (3) dental emergency [1st is Pulpal
infection (14%-25%), followed by pericoronitis
(10%-11%)].Among all emergency dental
conditions, periodontal abscesses represent

Oral and Maxillofacial Surgery and Periodontology 92

 J Bagh College Dentistry Vol. 23(3), 2011
approximately 8% of all dental emergencies in
the world (3), and up to 14% in the USA.(4,5)
Diabetes mellitus is a syndrome of abnormal
carbohydrate, fat and protein metabolism that
results in acute and chronic complications due to
the absolute or relative lack of insulin. There are
three general categories of diabetes: type 1,
which results from an absolute insulin
deficiency; type 2, which is the result of insulin
resistance and an insulin secretory defect; and
gestational, a condition of abnormal glucose
tolerance during pregnancy (6). The aim of this
study is to compare the periodontal health status
and prevalence of periodontal abscess between
controlled and uncontrolled type 2 diabetic
patients.
MATERIALS AND METHODS
Human sample and design
Type 2 diabetic patients included in this study
were drawn from Al-Mustansiriya University
National Diabetic Center. Sixty four patients
were enrolled in this study. Periodontal hygiene
status was assessed by means of a self reported
questionnaire (appendix) which included general
information: name, age, periodontal parameters
(plaque index, gingival index, probing pocket
depth and number and location of teeth with
periodontal abscess). Those patients were
divided into two groups according to fasting
blood sugar test and history (6):
1) Group 1 (controlled): thirty two type 2 diabetic
patients with fasting blood sugar between (80-
120 mg/dl).
2) Group 2 (uncontrolled): thirty two type 2 diabetic
patients with fasting blood sugar more than (120
mg/dl).
The participants should not have any other
systemic diseases than diabetic mellitus and
should not be under medication for other
systemic diseases affecting on periodontal health.
The study is cross sectional, all participants were
carefully informed about the aims of the
investigation and they were free to withdrawn at
any time during the study. Oral examinations
were done in the same visit. All participants were
selected regardless the periodontal health status
and sex but adjusted according to type 2 diabetic
mellitus.
Oral examination:
Oral examination was performed in a dental
clinic, on a dental chair; all periodontal variables
were recorded on four sites (mesial, buccal, distal
and lingual) for all teeth except the third molar
which was excluded.
The collected data include:-
Oral and Maxillofacial Surgery and Periodontology 93
Prevalence of periodontal abscess
(1) Assessment of dental plaque by (plaque
index system (PLI)) according to Sillness and
Loe(7).
(2) Assessment of gingival inflammation by
(gingival index system (GI)) according to Loe
and Sillness (8).
(3) Probing pocket depth measurement (PPD).
The PPD measurement has been performed using
William probe and use a score for ease of
estimation it involve the following criteria:
Score 0: Those include depth from 0-3 mm.
Score 1: Those include depth from 4-5 mm.
Score 2: Those include depth from 6-7 mm.
Score 3: Those include depth more than 8 mm.
(4) Recording teeth with periodontal abscess
RESULTS
Sixty four type 2 diabetic patients were enrolled
in this study, they divided into two groups: 1)
uncontrolled group: in which 32 patients were
examined, the results in this group was that 708
teeth and 2832 surfaces were examined with 8
patients suffering from periodontal abscess and
32 teeth affected by periodontal abscess. 2)
controlled group: : in which 32 patients were
examined, the results in this group was that 728
teeth and 2912 surfaces were examined with 3
patients suffering from periodontal abscess and 9
teeth affected by periodontal abscess as shown in
table 1.
Inter group comparisons between controlled and
uncontrolled groups for significant difference of
mean plaque index scores, mean gingival index
scores, percentage of different scores of probing
pocket depth, number of patients with
periodontal abscess and number of teeth with
periodontal abscess were carried out by statistical
analysis and the results showed the following:
1-Plaque index (PLI)
The result of present study showed that the
means of plaque index were higher in
uncontrolled patients =1.375±0.690 compared
with controlled patients =1.158±0.857. The inter
group comparison for plaque index between both
groups showed that there was a non significant
difference between them where the p.value >0.05
as shown in table 2 and table 3.
2- Gingival index (GI)
The result showed that the means of gingival
index were higher in uncontrolled patients
=1.568±0.814 compared with controlled patients
=1.142±0.626. The inter group comparison for
gingival index between both groups showed that
there was a significant difference between them
where the p.value <0.05 as shown in table 2 and
table 3.
J Bagh College Dentistry Vol. 23(3), 2011
3- Probing pocket depth (PPD)
The number and percent of sites that were
scored as 0 were 2756 (97.3%) in uncontrolled
patients and they were 2822 (96.9%) in
controlled patients. The number and percent of
sites that were scored as 1 were 46 (1.62%) in
uncontrolled patients and they were 63 (2.16%)
in controlled patients. The number and percent of
sites that were scored as 2 were 30 (1.06%) in
uncontrolled patients and they were 27 (0.93%)
in controlled patients. The inter group
comparison between both groups was performed
by using chi-square and the results showed that
there was non significant differences (p. >0.05)
as shown in table 4.
4- Periodontal abscess
The results showed that the number of patients
with periodontal abscess was (8) with a percent
(25%) and (32) teeth affected by periodontal
abscess in uncontrolled group while in controlled
group the number of patients with periodontal
abscess was (3) with a percent (9.375%) and (9)
teeth affected by periodontal abscess as shown in
table (5). Inter group comparison of percent of
patients with periodontal abscess between
uncontrolled and controlled groups showed there
was non significant differences (p. >0.05) while
the comparison of percent of teeth affected by
periodontal abscess between both groups was
significant (p. <0.05) by using chi-square as
shown in table 5.
The frequency distribution of periodontal abscess
in this study showed that the lower anterior teeth
were most affected followed by upper anterior
teeth then lower posterior teeth.
DISCUSSION
1-Dental plaque
More plaque accumulation was found in
uncontrolled group compared with controlled
group with no significance difference in this
study, this may be attributed to that many studies
(9)
suggested that the outcome of tooth brushing
is dependent on many factors, and one of these
factors is the skill of the individual using the
Oral and Maxillofacial Surgery and Periodontology 94
Prevalence of periodontal abscess
brush. So the controlled group may manipulate
with toothbrush better uncontrolled group.
2-Gingival index
Significant difference was found between
uncontrolled group and controlled group with
elevated gingival index in uncontrolled group
compared with controlled group, one explanation
for our results that these alterations of gingival
index follow physiologic changes related to the
disease process (more plaque accumulation
uncontrolled group lead to more gingival
inflammation than controlled group),additionally
recent studies suggested that uncontrolled
diabetes is associated with an increased
susceptibility and severity of infections including
periodontal disease in which it alters the response
of periodontal tissue to local factors (10, 11).
3-Probing pocket depth
There was no significant difference between
uncontrolled and controlled groups regarding the
percent of sites with probing pocket depth
despite of more gingival inflammation in
uncontrolled group. This can be explained by
that the number of uncontrolled group (20) was
equal to the number of controlled group but the
number of teeth in uncontrolled group (708) was
less than that in controlled group (728) which
might be lost due to periodontal disease, so the
number of surfaces in uncontrolled group (2832)
was less than that in controlled group (2912)
which may affect statistic analysis regarding
probing pocket depth.
4-Periodontal abscess
There were more teeth affected with
periodontal abscess in uncontrolled group than in
controlled group with significant difference, this
is explained by that the recent studies suggested
that uncontrolled diabetes is associated with an
increased susceptibility and severity of infections
including periodontal disease in which it alters
the response of periodontal tissue to local factors
(10, 11)
.
The frequency distribution of periodontal
abscess according to teeth in this study is agreed
with a study of Jaramillo et al (12).
J Bagh College Dentistry Vol. 23(3), 2011 Prevalence of periodontal abscess

Table 1: Descriptive of controlled and uncontrolled groups

Uncontrolled group Controlled group
No. of patients 32 32
No. of teeth 708 728
No. of surfaces 2832 2912
No. of patients with periodontal abscess 8 3
No. of teeth with periodontal abscess 32 9

Table 2: Mean plaque index and mean gingival index for both groups
Uncontrolled group Controlled group
Plaque index Gingival index Plaque index Gingival index
Mean 1.375 1.568 1.158 1.142
SD 0.690 0.814 0.857 0.626

Table 3: Inter groups comparison of mean plaque index and mean gingival index between
uncontrolled and controlled groups
t-test P-value Sig
Plaque index 1.027 0.312 NS
Gingival index 2.164 0.038 S
*P<0.05 Significant
**P>0.05 Non significant

Table 4: Inter groups comparison of percents of scores 0,1,2,3 of probing pocket depth between
uncontrolled and controlled groups
Uncontrolled group Controlled group
P-value
No. % No. %
Score 0 2756 97.3 2822 96.9 0.322 NS
Score 1 46 1.62 63 2.16 0.303 NS
Score 2 30 1.06 27 0.93 0.297 NS
Score 3 0 0 0 0 -----
Total 2832 100 2912 100 -----
* Chi-square, P>0.05 Non Significant

Table 5: Inter groups comparison of percent of patients with periodontal abscess and of surfaces
affected by periodontal abscess between uncontrolled and controlled patients
Uncontrolled group Controlled group
Chi-square P-value
No. % N0. %
No. of patients 32 32 0.317
25.0 9.375
No. of patients with periodontal abscess 8 3 1.003 P>0.05
P-value 0.021 0.132 NS
No. of teeth 708 728 0.049
4.51 1.23
No. of teeth with periodontal abscess 32 9 2.025 P<0.05
P-value 0.0032 0.042 S

REFERENCES
1. Punit Vaibhav Patel, Sheela Kumar G, Amrita Patel.
Periodontal Abscess: A Review. Journal of clinical
and diagnostic research 2011 Apr; 5(2):404-9.
2. Huan Xin Meng. Periodontal Abscess. Ann
Periodontol 1999; 4:79-82.
3. Herrera D, Roldan S, Sanz M. T he periodontal
abscess:a review. J Clin Periodontol 2000; 27:377–86.
4. Becker W, Berg L, Becker BE. The long term
evaluation of periodontaltreatment and maintenance in
95 patients. Int J Periodontics Restorative Dent 1984;
2: 55–70.
5. McLeod DE, Lainson PA, Spivey JD. Tooth loss due
to periodontal abscess: a retrospective study. J
Periodontol 1997; 68:963–6.

Oral and Maxillofacial Surgery and Periodontology 95

J Bagh College Dentistry Vol. 23(3), 2011 Prevalence of periodontal abscess

6. Vanden Berghe et al.. Insulin Therapy in critically ill 10. Bartolucci EG, Parkes RB. Accelerated
patients. J Clin Endocrinol Metab, September 2009, periodontal breakdown in uncontrolled diabetes:
94(9):3164. Pathgenesis and treatment. Oral Surg Oral Med Oral
7. Sillness J, Loe H. Periodontal disease in pregnancy. II. Pathol 1981; 52:387.
Correlation between oral hygiene and periodontal 11. Safkan-Seppala B, Ainamo J. Periodontal
condition. Acta Odont Scand 1964; 22:121-135. conditions in insulin dependent diabetic mellitus. J
8. Loe H, Sillness J. Periodontal disease in pregnancy. I. Clin Periodontol 1992; 19:24.
prevalence and severity. Acta Odont Scand 1963; 21: 12. Jaramillo A, et. al.. Clinical and
533. microbiological characterization of periodontal
9. Frandsen A. Mechanical oral hygiene practices. In: abscesses. J Clin Periodontol 2005; 32: 1213-8.
Loe H, Kleinman DV. Dental plaque control measures
and oral hygiene practices. Oxford, Washington DC:
IRL Press 1986, pp. 93-116.

Oral and Maxillofacial Surgery and Periodontology 96

J Bagh College Dentistry Vol. 23(3), 2011 Oral hygiene and gingival

Oral hygiene and gingival health among overweight Iraqi

school – age children (clinical comparative study)
Kadhim J. Hanau. M.Sc (1)
Enas R. Naaom. M.Sc (2)
Reem H. Majeed . M.Sc (3)

ABSTRACT
Background: The impact of obesity on general human health status has been studied extensively in modern literature
as it found to be related to most systemic disease including cardiovascular, respiratory, metabolic and other
diseases. On the other hand, studies have found a strong association between obesity and various clinical and
pathological aspects of periodontal disease, but most of these studies were directed toward adult age group only
without inclusion of younger age groups. This matter calls for more researches to be directed toward these age
groups. This research was conducted to provide a baseline data that hopefully fill the gap of shortage of knowledge
in this vital subject.
Material and method: The sample of this research was consists of 180 children (90 girls & 90 boys) with age range (6 –
12). For each gender and according to their percentile ranking, the children were allocated into three subgroups
(healthy weight, at risk of overweight and overweight). Each group was consists of (30) children. All of children were
examined for Plaque Index (PLI), and bleeding on probing index (BOP).
Results: Greater values for PLI were recorded for children in overweight groups (1.36 for girls & 1.51 for boys) in
comparison to those in healthy (0.85 for girls & 0.98 for boys) and at risk (1.07 for girls & 1.91 for boys) groups. Greater
values for BOP were also recorded for children in overweight groups (0.43 for girls & 0.67 for boys) in comparison to
those in healthy (0.11 for girls & 0.13 for boys) and at risk (0.42 for girls & 0.35 for boys) groups. According to paired
sample t-test, most of these differences were found to be statistically highly significant. Non significant differences
were recorded between different study groups on gender basis.
Conclusion: This research has documents the relation of obesity to periodontal health in children regardless of their
genders, but more studies to explore different aspects of this relation still required.
Key words: Obesity. Periodontal disease. BMI. BOP. PLI. (J Bagh Coll Dentistry 2011;23(3): 97-101).

INTRODUCTION BMI Weight Status

The global obesity epidemic has been described Below 18.5 Underweight
by the World Health Organization (1) as one of the 18.5 – 24.9 Normal
most blatantly visible, yet most neglected, public 25.0 – 29.9 Overweight
health problems that threatens to overwhelm both 30.0 and Above Obese
developing and developed countries (2). It also
represents a complex chronic condition that
For children and teens, after determining the
develops from an interaction of genotype and the
BMI, the BMI number is plotted on the BMI-for-
environment (3).
age growth charts for either girls or boys
Body Mass Index (BMI) is a simple index of
(Appendices I & II) to obtain a percentile ranking.
weight-for-height that is commonly used to
The percentile indicates the relative position of
classify peoples according to their weight. It is
the child's BMI number among children of the
defined as the weight in kilograms divided by the
same sex and age. BMI-for-age weight status
square of the height in meters (kg/m2). According
categories and the corresponding percentiles are
to the national center for health statistics (NCHS),
shown in the following table:
this index used as flowing:
For adults 20 years old and older, the BMI chart
results are interpreted using standard weight status Weight Status
Percentile Range
categories that are the same for all ages and for Category
both men and women. The standard weight status Underweight Less than the 5th percentile
categories associated with BMI ranges for adults 5th percentile up to the 84th
Healthy weight
are shown below: percentile
At risk of 85th to less than the 95th
(1) Assistant professor. Head department of Oral surgery and overweight percentile
Periodontology / College of dentistry/ Al- Mustansiryia
Equal to or greater than the
University. Overweight
(2) Assistant lecturer: department of Oral surgery and 95th percentile
Periodontology College of dentistry/ Al- Mustansiryia University.
(3) Assistant lecturer: department of POP College of dentistry/
Al- Mustansiryia University. The impact of obesity on general human health
status has been studied extensively in modern

Oral and Maxillofacial Surgery and Periodontology 97

J Bagh College Dentistry Vol. 23(3), 2011
literature. Obesity found to be related to most
systemic disease including cardiovascular as
hypertension (4), diabetes mellitus (5), respiratory
allergies (6), bone and joint diseases as
osteoarthritis (7) and also cancers including breast,
colon, endometrial, esophageal, hepatocellular,
renal gland and prostate (8).
Association of obesity to periodontal health was
also explored in last decades through several
studies on both animal (9) and human (10) levels. A
various cross-sectional and case-control studies
have found a strong association between obesity
and various clinical and pathological aspects of
periodontal disease (11-15). In addition to that,
studies found differences in composition of the
subgingival microbiota in individuals who
exhibited different BMIs (16).
An accepted explanation for this relation may
come from the fact that adipose tissue is an active
endocrine organ that secretes numerous cytokines,
or protein mediators, collectively known as
adipokines. These inflammatory mediators have a
potent role in both inflammation and immune
responses associated with periodontal disease. (17).
Unfortunately, two notes have been observed
regarding the researches that studied the relation
between obesity and periodontal disease: first, the
number of theses studies is so small to completely
explore this vital area and second, most of these
studies were directed toward adult age group only
without inclusion of younger age groups. These
facts strongly call for increasing the number of
such studies on one hand and directing the
researchers toward including younger age groups
in their researches on the other hand.
In Arabian Middle East countries, particularly in
Iraq, there was only few studies regarding this
subject (18, 19), most of them have focused on
adults, and again no study (according to our
knowledge) has been carried out in younger age
group. So this research was conducted to provide
a baseline data that hopefully fill the gap of
shortage of knowledge in this vital area of
research.
MATERIALS AND METHODS
Permission was taken from the concerned
authority to conduct this research on a school age
children in a number of primary schools in
Baghdad. The sample of this research was
consists of 180 children (90 girls & 90 boys) with
age range (6 – 12). They all were healthy and
have no history of any systemic disease.
All of children were examined for Silness & Loe
Plaque Index (PLI), and bleeding on probing
index (BOP). All present teeth were examined and
a mean score per person then calculated for each
Oral and Maxillofacial Surgery and Periodontology 98
Oral hygiene and gingival
index. The clinical examinations were in the
classrooms under the day light using 30
examination sets consisting of plane dental
mirrors and color coded WHO probes. These
instruments were properly sterilized and prepared
before each examination. All examinations were
conducted by the researchers themselves after
being well trained and calibrated.
The weight and height of each child then
measured using a digital weight scale and tape
measure to calculate their BMI, the BMI number
is plotted on the BMI-for-age growth charts
(appendices I & II) for either girls or boys to
obtain a percentile ranking. For each gender, the
children were allocated into three subgroups
according to their percentile ranking, (healthy
weight, at risk of overweight and overweight).
Each subgroup was consists of 30 children.
Collected data then submitted to both descriptive
and inferential statistical analysis using SPSS
v.15.0 program for windows.
RESULTS
Descriptive Statistics for both parameters in all
study groups including; means, standard
deviation, minimum & maximum values of the
study parameters, distribution of the sample by
gender and allocation of the sample to different
study groups were all showed by table (1). From
this table, the observer can conclude that greater
values for PLI were recorded for children in
overweight groups (1.36 for girls & 1.51 for boys)
in comparison to those in healthy (0.85 for girls &
0.98 for boys) and at risk (1.07 for girls & 1.91
for boys) groups. In concurrent with these finding,
greater values for BOP were also recorded for
children in overweight groups (0.43 for girls &
0.67 for boys) in comparison to those in healthy
(0.11 for girls & 0.13 for boys) and at risk (0.42
for girls & 0.35 for boys) groups.
In more detailed comparative figure (table 2), the
paired sample t-test for study parameters in girls
showed that differences in PLI were significant
between healthy & at risk groups and highly
significant between healthy & overweight groups
and between at risk & overweight groups. For
BOP, the differences were highly significant
between healthy & at risk and between healthy &
overweight groups, but it was non significant
between at risk & overweight groups.
On the other hand (table 3) showed that paired
sample t-test for both study parameters in boys
revealed highly significant difference between
healthy & at risk, healthy & over weigh and at
risk & overweight groups respectively.
Table (4) showed the paired sample t-test of
study parameters on a gender bases. From this
J Bagh College Dentistry Vol. 23(3), 2011
table it is clear that the differences between
matched groups of girls & boys were not
significant for both study parameters. One
exception of this rule has been observed, the
difference in BOP between overweight girls and
boys was significant.
DISCUSSION
In addition to the role of adipokines in the
pathogenic mechanisms of periodontal disease,
other potential mechanisms can explain the
association of obesity with periodontal disease as:
unhealthy dietary patterns with insufficient
micronutrients and excess sugar and fat content
may increase the risk of periodontal disease (12).
Changes in host immunity and/or increased stress
levels associated with gain of excess fat may also
play a role (20). Obesity may also influence
periodontal disease status by increasing lipid and
glucose blood levels, which may in turn have
deleterious consequences for the host response by
altering T cells and monocyte / macrophage
function, as well as increasing cytokine
production (21). Exercise capacity, which is closely
associated with obesity, has been also reported to
be related to periodontal disease (22).
Important of this research can be summarized in
two points: first, it may be (according to our
knowledge) the path finder research in its subject
in Iraq and can enrich the very poor data
regarding the relation of obesity to periodontal
disease in children on a global level. Second,
carrying out this research on a school age children
takes its importance from the well accepted fact
that identification of periodontal disease in
younger age group is very important in term of
prevention and providing primary health care for
affected children.
The findings of the present study provide another
supporting clue on the relation of obesity to oral
hygiene level and gingival health. This is very
clear from the greater values of study parameters
among overweight children in comparison to
healthy ones. The addition advantage of this
research is represented by providing a useful
baseline data on this relation in younger age
group, the data that is clearly not available in our
area in general and in our country in particular.
Using of BOP instead of Gingival Index (GI) can
be explained by the objective of this study, as it
was aimed at providing a quick glance on this
relation on one hand, and by the easier use of this
index in comparison to GI on the other hand. The
non significant differences of the results in both
genders may indicate that obesity has its effect on
periodontal health regardless of the gender.
However it is not significant, the slight difference
Oral and Maxillofacial Surgery and Periodontology 99
Oral hygiene and gingival
in study parameters between girls and boys (in
favorite of girls) may indicates that girls take care
of themselves better than boys did.
REFERENCES
1. World Health Organisation: Obesity and overweight.
Available online at
www.who.int/dietphysicalactivity/publications/facts/
obesity/en/ 2009.
2. Linden G, Patterson C, Evans A, Kee F. Obesity and
periodontitis in 60-70-year-old men. J Clin
Periodontol 2007; 34: 461-6.
3. Dennison EM, Syddall HE, Aihie Sayer A, Martin
HJ, Cooper C; Hertfordshire Cohort Study Group.
Lipid profile, obesity and bone mineral density: the
Hertfordshire Cohort Study. QJM 2007; 100(5):297–
303.
4. Ronald M. Krauss, MD, Mary Winston Ed D,
Barbara J, Fletcher RN, Scott M, Grundy MD.
Obesity: Impact on Cardiovascular Dis circulation
1998; 98.
5. Pan DA, Lillioja S, Kriketos AD, Milner MR, Baur
LA, et al. Skeletal muscle triglyceride levels are
inversely related to insulin action. Diabetes 1997;
46: 983-8.
6. Bergeron C, Boulet LP, Hamid Q. Obesity, allergy
and immunology. J Allergy Clin Immunol. 2005;
115: 1102-4.
7. Creamer P, Hochberg MC. Osteoarthritis. Lancet
1997; 350:503-8.
8. Richard N. Redinger. Textbook of gastroenterology
and hepatology. 2007;11:3: 856-63.
9. Perlstein MI, Bissada NF. Influence of obesity and
hypertension on the severity of periodontitis in rats.
Oral Surg Oral Med Oral Pathol 1977; 43: 707–19.
10. Saito T, Shimazaki Y. Metabolic disorders related to
obesity and periodontal disease. J Periodontology,
2007; 43: 254–66.
11. Wood N, Johnson RB, Streckfus CF. Comparison of
body composition and periodontal disease using
nutritional assessment techniques. Third National
Health and Nutrition Examination Survey
(NHANES III). J Clin Periodontol 2003; 30: 321-7.
12. Al-Zahrani MS, Bissada NF, Borawskit EA. Obesity
and periodontal disease in young, middleaged, and
older adults. J Periodontol 2003; 74: 610-5.
13. Alabdulkarim M, Bissada N, Al-Zahrani M, Ficara
A, Siegel B. Alveolar bone loss in obese subjects. J
Int Acad Periodontol 2005;7: 34-8.
14. Nishida N, Tanaka M, Hayashi N, Nagata H,
Takeshita T, Nakayama K, Morimoto K, Shizukuishi
S. Determination of smoking and obesity as
periodontitis risks using the classification and
regression tree method. J Periodontol 2005;76:923-
8.
15. D’Aiuto F, Sabbah W, Netuveli G, Donos N,
Hingorani AD, Deanfield J, Tsakos G. Association
of the metabolic syndrome with severe periodontitis
in a large U.S. population-based survey. J Clin
Endocrinol Metab 2008; 93: 3989-94.
16. Anne D. Haffajee, Sigmund Sidney Socransky:
Relation of body mass index, periodontitis and
Tannerella forsythia. J Clinic Periodontol 2009; 36:
2: 89–99.
J Bagh College Dentistry Vol. 23(3), 2011 Oral hygiene and gingival

17. Page RC: The role of inflammatory mediators in the
pathogenesis of periodontal disease. J Periodont Res
1991; 26:230.
18. Khader YS, Bawadi HA, Haroun TF, Alomari M,
Tayyem RF. The association between periodontal
disease and obesity among adults in Jordan. J Clinic
Periodontol 2009; 36(1): 18-24.
19. Abbood HM. Experimental gingivitis in overweigh
subjects (clinical and microbiological study). M.Sc
thesis in Periodontology. College of dentistry.
University of Baghdad. 2010.
20. Reeves AF, Rees JM, Schiff M, Hujoel P. Total
body weight and waist circumference associated
with chronic periodontitis among adolescents in the
United States. Arch Pediatr Adolesc Med 2006;160:
894–9.
21. Gurpreet Kaur, N.D.Gupta Lata Goyal obesity and
periodontal disease. Indian J Dent Scienc 2010; 2:5:
33-5.
22. Merchant A T, Pitiphat W, Rimm EB, Joshipura K.
Increased physical activity decreases periodontitis
risk in men. Eur J Epidemiol 2003; 18: 891–8.

Table 1: Descriptive Statistics for both parameters in all study groups

Gender Index Group N Min. Max. Mean S.D
Healthy 30 .08 1.58 .8527 .43361
PLI At risk 30 .29 1.58 1.0717 .27723
Overweight 30 .62 1.92 1.3630 .37490
Girls
Healthy 30 .00 .63 .1188 .15316
BOP At risk 30 .00 .92 .4229 .27648
Overweight 30 .00 1.00 .4359 .37340
Healthy 30 .25 1.45 .9843 .31386
PLI At risk 30 .80 1.75 1.1960 .21548
Overweight 30 .83 2.00 1.5187 .30804
Boys
Healthy 30 .00 .50 .1319 .14587
BOP At risk 30 .00 .75 .3575 .18635
Overweight 30 .00 1.00 .6722 .39420

Table 2: Paired sample t-test for both study parameters in girls

Paired differences
Index Compared groups T SIG
Mean S.D S.E
Healthy – At risk -.21900 .44611 .08145 -2.689 .012
PLI Healthy – Overweight -.51033 .52299 .09548 -5.345 .000
At risk – Overweight -.29133 .45846 .08370 -3.481 .002
Healthy – At risk -.30407 .30363 .05544 -5.485 .000
BOP Healthy – Overweight -.31703 .37737 .06890 -4.602 .000
At risk – Overweight -.01297 .55234 .10084 -.129 .899

Table 3: Paired sample t-test for both study parameters in boys

Paired differences
Index Compared groups T SIG
Mean S.D S.E
Healthy – At risk -.21167 .34056 .06218 -3.404 .002
PLI Healthy – Overweight -.53433 .35938 .06561 -8.144 .000
At risk – Overweight -.32267 .35988 .06571 -4.911 .000
Healthy – At risk -.22560 .20719 .03783 -5.964 .000
BOP Healthy – Overweight -.22560 .20719 .03783 -5.964 .000
At risk – Overweight -.31470 .36295 .06627 -4.749 .000

Table 4: Paired sample t-test comparison for study parameters between girls and boys
Paired differences
Index Compared groups T SIG
Mean S.D S.E
Healthy girls – Healthy boys -.13167 .49043 .08954 -1.470 .152
PLI At risk girls – At risk boys -.12433 .35890 .06553 -1.897 .068
Overweight girls – Overweighted boys -.15567 .45557 .08318 -1.872 .071
Healthy girls – Healthy boys -.01310 .20190 .03686 -.355 .725
BOP At risk girls – At risk boys .06537 .39566 .07224 .905 .373
Overweight girls – Overweighted boys -.23637 .47300 .08636 -2.737 .010

Oral and Maxillofacial Surgery and Periodontology100

J Bagh College Dentistry Vol. 23(3), 2011 Oral hygiene and gingival

Appendix I,II

Oral and Maxillofacial Surgery and Periodontology101

J Bagh College Dentistry Vol. 23(3), 2011 Measurements of periodontal

Measurements of periodontal temperature & its

comparison to the crevicular fluid flow in the assessment
of periodontal disease severity
Enas Sh Hamad B.D.S. (1)
Maha Sh AL-Rubaie B.D.S, M.Sc . (2)

ABSTRACT
Background: In periodontics, there is a need for objective measurements in monitoring disease processes& in
assessing the effectiveness of treatment. Elevated temperature is one of 4 cardinal inflammatory signs& is a potential
indicator of periodontal disease. The purpose of this study was to determine& compare the severity of periodontal
disease by subgingival temperature measurements in health& disease state, determine the correlation between
periodontal parameters (bleeding on probing& probing depth) and subgingival temperature measurements&
compare gingival crevicular fluid (GCF) flow with subgingival temperature.
Material & Methods: 10 male subjects ranging in age (35-55) years were measured at 4 sites per tooth for subgingival
temperature, GCF flow, probing pocket depth& bleeding on probing.GCF collected by means of endodontic paper
points size 30. Subgingival temperatures were measured using digital thermometer while sublingual temperature was
measured by sublingual digital thermometer. To compensate for subject-to-subject variations in core temperature,
site temperatures were measured& expressed as a difference relative to sublingual temperature. Following
measurement of subgingival temperature, probing depth& bleeding on probing were recorded using periodontal
probe.
Results: The results indicated that subjects differed in their mean temperature difference. Similarly, temperature at a
site in relation to its location in the mouth, pocket depth, bleeding on probing, GCF flow& inflammatory status.
Analysis of the results revealed a significant (p<0.05) difference between mean temperature difference of healthy&
diseased sites, anterior& posterior, maxillary& mandibular teeth for both healthy& diseased sites. A natural posterior to
anterior temperature gradient was observed with the posterior sites being hotter than the anterior sites& mandibular
sites hotter than maxillary sites. Tooth by tooth analysis showed that diseased teeth have higher temperature than
anatomically equivalent healthy teeth. Subgingival temperature also correlates significantly (p<0.05) with certain
clinical parameters like probing depth, bleeding on probing while GCF flow differed significantly from subgingival
temperature.
Conclusion: subgingival temperature measurements can be used as a successful mean of diagnosis or monitoring
periodontal condition, but additional studies are necessary to develop thermometry as a diagnostic aid in
periodontal practice.
Key words: Subgingival temperature, periodontal disease severity. (J Bagh Coll Dentistry 2011;23(3): 102-108).

INTRODUCTION Temperature measurement of the periodontium

Periodontal disease is one of the most
widespread diseases of mankind. No nation & no
region of the world being free from .These
diseases are group of chronic infectious diseases
resulting in inflammation of the gingival and/or
periodontal tissues with progressive loss of
alveolar .
Chronic periodontitis, a common disease of
microbial origin, is the common cause of tooth
loss in adult humans. The disease serves as a
convenient experimental model for analysis of
many aspects of chronic . Heat
or elevated temperature is one of the four
cardinal inflammatory signs (redness, swelling,
heat & pain) and it is the only one which can be
measured quantitatively & .
(1) M.Sc. Student , Department of Periodontics College of
dentistry of, University of Baghdad
(2) Assistant Professor, Department of Periodontics College of
dentistry of, University of Baghdad
may therefore act as a useful means of diagnosis
of periodontitis since subgingival temperature
can be measured accurately & reliably & can
differentiate clinically defined periodontally
healthy & diseased .
Furthermore, in certain selected cases, when
used in conjunction with other clinical &
microbial parameters, subgingival temperature
can indicate progressing periodontal disease in
untreated subjects & prognosis in periodontal
It has been concluded that increased temperature
is an indicator of periodontal disease& that the
measurement of increased temperature could act
as a fast screening process for inflammatory
periodontal
GCF flow is an important determinant in the
ecology of the periodontal pocket or sulcus. It
creates a flushing action & an isolation effect. In
addition, it probably determines the growth level
of subgingival microorganisms& is a potential
marker for periodontal disease .

Oral and Maxillofacial Surgery and Periodontology102

J Bagh College Dentistry Vol. 23(3), 2011
As we couldn't find any previous studies in Iraq
regarding the measurement of subgingival
temperature in health & disease periodontal
conditions, it was decided to conduct this study
to measure the subgingival temperature in
healthy and diseased periodontal sites and
correlate it with clinical periodontal parameters
(GCF flow , bleeding on probing & probing
depth).
MATERIALS & METHODS
Subjects included in the study were drawn from
patients attending the Department of Periodontics
in Teaching Hospital of Dentistry College-
Baghdad / Iraq, also from Al-Greaat health
center. Ten Iraqi male patients enrolled in the
study. All were over 35 years of age & up to 55
years. The selection criteria for the patients
were as follows: Patients had 20 or more natural
teeth; they had many periodontal pockets of
various depths. Thus the temperature of a large
number of periodontal pockets was measured
from small population, which reduced the subject
The exclusion criteria included:
smoking, History of any systemic disease,
Medication, which could modify the
inflammatory response, Systemic antibiotic
therapy &/or periodontal therapy including
scaling or root planning within the preceding 3
months.
For each subject 4 assessments were made:
measurements of GCF flow on selected teeth of
different probing pocket depths. Measurement of
subgingival temperature, probing depth &
bleeding upon probing was taken at 4 sites per
tooth (buccal, lingual, mesial, distal), 3rd molars
were excluded.
In the study we have certain definition for
health & disease that involve:
1. Health: included any site of probing depth 1,
2,3 mm which did not bleed upon probing.
2. Disease: included site with probing depth of 4
mm or more with or without bleeding upon
probing.
Oral examination was performed in a dental
clinic, we started with the measurements of
crevicular fluid flow. Following the selection of
the periodontally diseased subjects, a minimum
of 8 and up to 16 non- adjacent sites were
selected in each subject that had a probing depth
<4 mm , 4-5mm & > 6 mm .
When the patients selected fulfill our criteria, we
arrange two visits to him. In the 1st day we
instruct him to avoid oral hygiene measures &
eating for 12 hours prior to the time of fluid
collection & we measure the probing depth in
order to select teeth with different probing depths
Oral and Maxillofacial Surgery and Periodontology103
Measurements of periodontal
for fluid collection. In the 2nd day we start to
collect the GCF. Each gingival site was isolated
with cotton rolls & gently dried with compressed
air. A paper point was carefully inserted into
each gingival crevice until the examiner felt
slight . After remaining in place
for 30 , any paper point visibly
contaminated with blood or saliva should be
discarded & one paper point is used for each site.
After removal, the paper points were moisture
with alcoholic solution of ninhydrin at a
concentration varying between 0.2 % - 2 % &
allowed to . Since ninhydrin reacts with
the amino acids in the exudate to give a blue
coloration, the areas of the paper points, which
had taken up gingival exudates, were stained
blue. The lengths of the colored parts of the
paper points were measured with vernier. All
paper points having colored areas less than half a
millimeter were also given a value of 0.5 mm
A scale of GCF length has been designed to code
its scores as follows: Score 0(0.5-1.9) mm Score
1(2-3.4) mm. The GCF measurements involving
only 160 sites.
Following these measurements, temperature had
been measured .To eliminate temperature
variation from other influences, subjects were
required to refrain from eating, drinking for at
least 30 min.s prior to the dental examination.
Initially the sublingual temperature was
measured by placing the sublingual thermometer
in the sublingual region, the subjects asked to
seal the lips & not to move the tongue until the
temperature recording had been ,
as in figure (1)
(Figure 1) Sublingual temperature measurement
The subgingival digital thermometer was not
available in our local market and it was brought
from outside Iraq & it has certain characteristics
in the design of its probe, these involve:
1. The probe tip dimension is similar to a
conventional depth probe thus preserving the
probing technique.
J Bagh College Dentistry
2. The response time is fast (< 1s) to permit rapid
full mouth assessment.
3. Accuracy & reproducibility are better than 0.2
degree centigrade.
4. The probe tip material used not change the
local temperature environment. Subgingival
temperature measurements were taken at the
same 4 sites per tooth (buccal, lingual, mesial,
and distal) after initially determining the
sublingual temperature.
Site measurements (subgingival temperature
measurements) were taken by gently inserting the
tip of the probe into the gingival sulcus or pocket
at the sites to be measured & kept in place until
the digital display had stabilized as in figure (2).
(Figure 2) subgingival temperature measurement
Temperature measurements involving 932
sites. It was decided not to repeat the
temperature measurements as it has been shown
that the physical stimulation of the 1st reading
may affect subsequent temperature readings &
bleeding assessment (13)
The sublingual measurements were averaged &
used to normalize temperature values. All the
data were analyzed using the difference between
the subgingival & sublingual temperatures
(temperature differential). This normalization
scheme eliminate subject to subject systemic
temperature variations & minimizes effects due
to diurnal temperature changes of a subject (6), (14).
Following measurement of subgingival
temperature, probing depth were recorded using
periodontal probe .Probing pocket depth
measurement involved 932 sites.
The depth of the sulcus or pocket was
determined by gently inserting a periodontal
probe between the tooth & oral sulcular
epithelium until resistance was felt. The distance
from the tip of the probe to the free gingival
margin was measured & recorded to the closest
millimeter. No pressure was used; the probe was
allowed to fall by its own weight.
A scale has been designed to code the
probing depth scores according to the following
Oral and Maxillofacial Surgery and Periodontology104
Vol. 23(3), 2011 Measurements of periodontal
criteria Grade 0 (1-3 mm), Grade 1 (4-5 mm),
Grade 2 ( 6 mm)
Then bleeding on probing was measured. The
gingiva was lightly dried with compressed air &
the periodontal probe inserted to the deepest
point into the gingival crevice until slight
resistance was felt. The probe was run gently
using minimal axial force to avoid undue
penetration in the tissue. This procedure is
carried out at 4 sites of the tooth (mesial, distal,
lingual, buccal) . The presence or absence of
bleeding upon probing from each site is recorded.
If the bleeding occurs within 30 sec., the site was
given +ve score (1) & -ve score for non-bleeding
site , 932 sites involved in this
measurement.
Statistical analyses: data are calculated and
entered into a computerized data base structure.
Statistical analysis was done using SPSS
software. Mean and SD, t-test, chi square,
correlation coefficient (r) were used where
indicated. Level of significance is 0.05.
RESULTS
The total of 10 male subjects were included
in the study, their sublingual temperature range
was (36.5-37.2) ºC. Table (1) summarizes the
clinical characteristics of the subjects. As a
starting point for the analysis, average site
temperatures of each tooth in all subjects was
calculated to determine whether there were
differences between the teeth in all subjects. The
data were further analyzed on a site basis. Site
data from the 10 male subjects were pooled to
determine the temperature characteristics of those
subjects. Table (2) demonstrated the mean
temperature difference & standard deviations of
diseased & healthy sites of upper teeth (anterior&
posterior, left& right). t-test was applied to test
the significance of difference between diseased&
healthy sites for both anterior & posterior teeth.
Sites were classified as diseased if they have a
pocket depth (>4mm) & healthy if they have a
probing depth of (1, 2,3)mm. With this
classification, there were (48) diseased upper
anterior sites, (189) healthy upper anterior sites,
(78) diseased upper posterior sites, (149) and
healthy upper posterior sites. The table showed
a highly significant difference in the mean
temperature difference for both healthy and
diseased sites of anterior and posterior maxillary
teeth.
Table (3) showed the mean temperature
difference& standard deviations of diseased&
healthy sites of all mandibular teeth, we have
(59) diseased lower anterior sites, (180) healthy
J Bagh College Dentistry Vol. 23(3), 2011 Measurements of periodontal

lower anterior sites, (93) diseased lower posterior
sites& (136) healthy lower posterior sites. t-test
was applied to test the significance of difference
of diseased& healthy sites for both anterior&
posterior teeth and it revealed a highly significant
differences. A general characteristic of the mean
temperature difference by arch, region& health
status was represented by table (4). It showed a
significant difference between maxillary and
mandibular posterior and anterior teeth for both
healthy and diseased sites .
Table (5) showed the distribution of sites
according to different probing depth grades. The
results showed that 69.635% of sites have grade
0, 29.077% of sites have grade 1& only 1.180%
of sites have grade 2. Table (6) demonstrated the
correlation of mean temperature difference&
probing pocket depth by applying correlation
coefficient (r).It revealed significant strong
correlation between mean temperature
difference& grade0(1,2,3)mm& grade2(>6)mm
probing depth. Weak but significant correlation
between mean temperature difference&
grade1(4,5)mm pocket depth was found.
Table (7) represented the frequency
distribution& percentages of sites according to
the presence or absence of BOP (bleeding on
probing). This table revealed that: 51.347% of
sites of anterior teeth represent BOP,60.34% of
sites of posterior teeth with BOP. Chi-square
test was applied to compare the presence or
absence of bleeding on probing in anterior&
posterior teeth.The results revealed a significant
difference between anterior& posterior teeth
regarding presence or absence of bleeding on
probing (p<0.05). Correlation of mean
temperature difference& bleeding on probing can
be estimated in table (8), in this table the
correlation coefficient of regression (r) was
applied to determine the correlation between
BOP& temperature difference of anterior&
posterior teeth. This table revealed high&
significant correlation between presence of
bleeding on probing in anterior& posterior teeth
(p<0.05)& mean temperature difference. For
GCF measurement we use two scores which
represent two different grades of fluid flow rate
or volume and in order to compare the GCF flow
with subgingival temperature we use two scores
also (0,1) which represent the corresponding
increased in temperature and as follows : GCF
Score 0 (0.5-1.9) mm , Score 1 (2-3.4) mm
Mean temperature difference Score 0 (0-1.5) ºC ,
Score 1 (1.6-3)ºC
The percentage& number of score 0& score 1
for both GCF& mean temperature difference was
illustrated in table (9). Chi-square test was
applied to compare GCF& mean temperature
difference and there was highly significant
difference (p< 0.0001) between them.

Table (1) clinical characteristics of subjects

Number of subjects 10 males
Age range 35-55y
Mean temperature difference 1.183ºC
Mean subgingival temperature 35.8ºC
Mean sublingual temperature 36.7ºC

Table 2: Mean Temperature difference and SD of anterior& posterior maxillary teeth (diseased
& healthy sites)

Diseased sites (pocket depth) Healthy sites (probing depth)

>4mm 1,2,3 mm
p-
Region Teeth Mean of Mean of t-test
value
No. Temperature SD No. Temperature SD
difference difference
14,15,16,17 0.001
Poster. 78 1.005 0.302 149 1.112 0.247 8.996
24,25,26,27 HS
11,12,13 0.001
Anter. 48 1.431 0.202 189 1.846 0.156 4.600
21,22,23 HS

Oral and Maxillofacial Surgery and Periodontology105

 J Bagh College Dentistry Vol. 23(3), 2011 Measurements of periodontal

Table 3: Mean Temperature difference and SD of anterior& posterior mandibular teeth

(diseased& healthy sites)
Diseased sites (pocket depth) Healthy sites (probing depth
>4 1,2,3 mm)
Region Teeth
Mean of Mean of t-test P-value
No. Temperature SD No. Temperature SD
difference difference
44,45,46,47 0.001
Posterior 93 0.573 0.211 136 0.720 0.275 9.58
34,35,36,37 HS
41,42,43 0.0018
Anterior 59 1.096 0.242 180 1.396 0.197 2.710
31,32,33 HS

Table 4: Mean& SD of temperature difference by arch, region& health status

Maxillary teeth Mandibular teeth
Mean Mean t-test P-value
Health
No. temperature SD No. temperature SD
status Region
difference difference
Healthy anterior 189 1.846 0.156 180 1.396 0.197 34.620 P<0.0001 HS
Disease anterior 48 1.431 0.202 59 1.096 0.242 30.854 P<0.05 S
Healthy posterior 149 1.112 0.247 136 0.720 0.257 9.728 P<0.05 S
disease posterior 78 1.005 0.302 93 0.573 0.211 9.754 P<0.05 S

Table 5: Frequency distribution& prcentages of sites according to different probing depth

grades
Probing depth grade Freq. %
Grade 0 (1,2,3) mm 649 69.635
Grade 1 (4,5) mm 271 29.077
Grade 2 (>6) mm 12 1.180

Table 6: correlation of mean temperature difference& probing pocket depth

Probing depth No. of sites Mean temperature difference r P-value
Grade0(1,2,3)mm 649 1.273 0.697 P<0.05 S
Grade1(4,5)mm 271 1.026 0.346 P<0.05 S
Grade2(>6)mm 12 0.85 0.877 P<0.05 S

Table 7: Frequency distribution of sites according to the presence or absence of bleeding on

probing
Freq. or No. of sites and % Chi-square p-value
Bleeding on probing (BOP)
Ant. Post Ant. Post. Ant. Post
Absent 230(48.625) 182(39.66) 0.0393 0.003
2.998 11.917
present 243(51.347) 277(60.34) S S

Table 8: Correlation of mean temperature difference & bleeding on probing

No. of sites Mean temperature difference SD r P –value
BOP
Ant. Post Ant. Post Ant. Post Ant. Post Ant Post
0.364 0.969
Absent 230 182 1.599 0.896 0.259 0.285 0.294 0.121
NS NS
0.007 0.01
present 243 277 1.450 0.862 0.233 0.299 0.882 0.663
S S

Table 9: Number and Percentage of GCF& mean temperature difference for selected teeth
GCF Mean temperature difference.
Chi-square P-value
No. % No. %
0 114 71.25 123 76.87 0.0001
74.348
1 46 28.75 37 23.13 HS

Oral and Maxillofacial Surgery and Periodontology106

J Bagh College Dentistry Vol. 23(3), 2011
DISCUSSION
At first consideration, the study of
subgingival temperature appears to be quite
simple& objective. However, many factors
become apparent which tend to complicate the
use of subgingival temperature, from these
factors, an accurate& reproducible measuring
device is . The investigation
provided detailed oral temperature characteristics
of the healthy& diseased periodontium. The
study was undertaken to determine whether site
temperature differences existed between
maxillary& mandibular, anterior& posterior,
diseased& healthy periodontium. Subgingival
temperatures were all lower than sublingual
temperatures. However, the use of temperature
differentials results in measures of subgingival
temperature that are independent of core
temperature& capable of providing unique
information about the inflammatory state.
Furthermore, temperature differential reduces the
number of subjects required to achieve
significance in clinical the site
temperatures were generally cooler than the
sublingual temperature except in few markedly
inflamed sites when the subgingival site
temperature approached that of the sublingual
. temperature measurements should be interpreted
The present investigation confirmed the
findings of previous
, that
the average subgingival temperature was almost
lower than the sublingual temperature. In
addition, there was a great deal of variation of
temperatures between teeth as pointed
previously. Thus, typically one might find that
posterior sites had temperatures within about
(0.3-0.9) ºC of core& anterior sites might be (1-
2.5) ºC below core. A natural- posterior to
anterior temperature gradient was observed, with
the posterior sites being hotter than the anterior
sites. The observed gradient is a natural
consequence of the cooling of blood as it
traverses along the arteries from the posterior
region to the anterior & this may be
explained in part by the anatomy& physiology of
the area. The periodontium in the anterior region
is apparently more sensitive to temperature
changes from environmental influences related to
mouth breathing& respiration through
the . Tooth-by-tooth analysis showed
that diseased teeth have higher temperatures than
anatomically equivalent healthy teeth.
Inflammation commonly accompanies pathologic
alterations of the connective tissues. Temperature
is one of the more attractive methods of
evaluating this response, since it lends itself to
Oral and Maxillofacial Surgery and Periodontology107
Measurements of periodontal
direct physical measurement. The increase in
cellular activity generates heat, which warms the
blood passing through the site, & it therefore
seems logical that the inflammatory cellular
activity in periodontitis would warm an
instrument inserted into the periodontal pocket.
Such an increase in temperature within a
periodontal pocket would thus be indicative of
disease severity. Conversely, if the temperature
within a pocket is not raised, it could be assumed
that there is a little or no inflammation in the
periodontal . In previous studies, the
difference between temperature difference values
for healthy& diseased sites ranged from
. There was a close agreement
between the difference in temperature
differentials value for healthy& diseased sites
found in the present study. In addition,
mandibular sites were reported to be warmer than
maxillary sites. The explanation for such
temperature difference between maxillary&
mandibular arches that the lower maxillary
temperatures are due to the cooling effect of the
airflow through the nasal cavities during
breathing& evaporation of fluid from the nasal
mucosa could contribute further to .
The findings of the present study suggest that
with caution. Although temperature has proven a
successful means of monitoring& diagnosing the
periodontal condition, factors such as probing
depth may influence temperature measurements.
Therefore, probing depth should be considered
when temperature is used as a mean of diagnosis
or monitoring periodontal health. It's clearly
obvious from the results that there is a significant
increase in temperature with increase in pocket
depth; but pocket temperature in general was
lower than sublingual temperature. A few deep
pockets were measurably warmer than the
sublingual temperature. The reason for this has
not been established, but might be that the
bottom of these deep pockets lay below the level
of the floor of the mouth, or the buccal mucosal
reflection respectively, but again the frequency of
these observations was . These results
coincide with the findings of other
,who stated that temperature
was increased with increasing of probing depth
suggesting a subsequent decrease of temperature
difference. Regarding bleeding on probing, the
results revealed a significant correlation between
bleeding on probing& mean temperature
difference for both anterior& posterior teeth&
this was in agreement with other
who reported higher subgingival
J Bagh College Dentistry
temperature with the presence of bleeding on
probing when compared with corresponding teeth
without bleeding on probing.
Regarding the differences in the volume& flow
rate of GCF between sample sites may be due to
variation in the anatomy& size of the gingival
crevices, the susceptibility of sites to
inflammation, or even the uptake of fluid with or
against the effect of . The sample
sites were chosen to be different in their
susceptibility to periodontal disease, but also
represent anatomically different tooth types,
which may be expected to lead to substantially
different pooled GCF volumes available for
sampling. The results of this study correspond to
other , that it was possible to
quantitate accurately the amount of exudate flow
rather than the migration coefficient of fluid on a
filter paper strip. It is clearly illustrated from the
results there was a highly significant difference
between mean temperature difference& GCF
flow. This was consistent with previous findings
in the literature which suggested an association
between GCF volume& clinical signs of
inflammation including "subgingival
temperature, pocket depth& bleeding on
. measurements II. The influence of different filter
In conclusion, subgingival temperature
measurement can be used as a successful mean of
diagnosis or monitoring periodontal conditions,
but additional studies are necessary to develop
thermometry as a diagnostic aid in periodontal
practice.
REFERENCES
1. Buatongsri V, Songpaisn Y, Hongprasong N,
Phantumvanit P, Clarke N. The distribution of severe
periodontitis in urban (Bankok) & rural (Payeoprovince)
high risk to stress group of Thai population. CU Dent J
2002; 25: 1-7.
2. Carranza FA& Bulkacz J: Defense mechanisms of the
gingival In: Clinical periodontology 10th ed WB
Saunders, USA, 2009, p.254-262.
3. Lindhe J, Karing T & Niklans PL: Clinical
periodontology & Implant Dentistry 5th ed. Munksgaard,
Copenhagen, 2008.
4. Wolf HF & Hassell TM, Color atlas of dental hygiene,
Tests of the host response-Risks 2006. P.188.
5. Niederman R, Kent R.Use of subgingival temperature
in periodontal clinical trials. Assessment of accuracy &
reliability. J Periodontal Res 1993; 28: 1-3.
6. Haffajee AD, Socransky SS, Goodson JM. Subgingival
temperature (I) Relation to baseline clinical parameters. J
Clinic Periodontol 1992a; 19: 401-408.
7..Haffajee AD, Sokransky SS, Goodson JM.
Subgingival temperature (II). Relation to future
periodontal attachment loss. J Clin Periodontol 1992b;
19: 409-416.
Oral and Maxillofacial Surgery and Periodontology108
Vol. 23(3), 2011 Measurements of periodontal
8.Dinsdale CRJ, Rawlinson A, Walsh TF. Subgingival
temperature in smokers & non-smokers with periodontal
disease. J Clin Periodontol 1997; 24: 761-766.
9. Niederman R, Naleway C, Buyle-Bodin Y, Robinson
P. Subgingival temperature as a gingival inflammatory
indicator. J Clin Periodontol 1995; 22: 804-809.
10. Brill N, Bjorn H. Passage of tissue fluid into human
gingival pockets. Acta Odontol Scand 1959; 17: 277-284.
11. Larry F Wolff, Nancy J, Koller, Quenton T Smith,
Ambika Mathur, Dorothee Aeppli. J Clin Periodontol
1997; 24: 900-906.
12.Orban JE, Stallard RE.Gingival crevicular fluid: a
reliable predictor of gingival health? J Periodontol 1969;
40: 231.
13. Holthuis AF, Chebib FS. Observations on
temperature pattern of the gingival (I). The effect of arch,
region & health. J Periodontol 1983; 54: 624-628.
14. Kung R.T, Ochs B, Goodson JM. Temperature as a
periodontal diagnostic. J Clin Periodontol 1990; 17: 557-
563.
15. Meyerov R, Lemmer J, Cleaton-Jones P, Volchansky
A Temperature measyrements in periodontal pockets. J
Periodontol 1991; 62: 95-99.
16. Maeda T, El Ghamrawy E, Kroone H., Runov J,
Stoltze K, Brill N. Crevicular temperature rises
stimulated by plaque formation. J Oral Rehab 1979; 6:
229-234.
17.Trikilis N, Rawlinson A, Walsh TF. Periodontal
probing depth & subgingival temperature in smokers &
non-smokers. J Clin Periodontol 1999; 26: 38-43.
18. Leirskar J. In vitro experiments on gingival exudate
papers& ascending and descending chromatography on
mobility. J Periodontol Res 1971; 6: 23-27.
19. Daneshmand H, Wade AB. Correlation between
gingival fluid measurements& macroscopic and
microscopic characteristics of gingival tissue. J
Periodontal Res 1976; 11: 35-46.
20. Giuseppe Perinetti, Giuseppe Spoto. The use of ISO
endodontic paper points in determining small fluid
volumes. Journal of Applied Research in Clinical
Dentistry 2004; 1: 1.
21. Holthuis AF, Gelskey SC, Chebib FS. The
relationship between gingival tissue temperatures &
various indicators of gingival inflammation. J Periodontol
1981; 52: 187-189.
22. Sidi AD, Ashley FP. Influence of frequent sugar
intakes on experimental gingivitis. J Periodontol 1984;
55: 419-423.
J Bagh College Dentistry Vol. 23(3), 2011 Effect of super dental floss

Effect of super dental floss on oral hygiene in patients with

fixed orthodontic appliances
Mohammed A.H. Al-Bahadli B.D.S., M.Sc.(1)

ABSTRACT
Background: orthodontic appliances contribute to plaque retention and interfere with the performance of good oral
hygiene. This study was conducted to find the effect of using super dental floss in the oral hygiene of orthodontic
patients.
Materials and methods: The study sample is comprised of 16 orthodontic patients (7 males and 9 females); ranging in
age from 15–22 years at the beginning of orthodontic treatment. The quantity of plaque were evaluated after one
week when patients wear orthodontic appliance then another recording was done after one week instruction of
using super dental floss. By using disclosing tablets we account the quantity of plaque. We assessed 12 anterior teeth
in each patient by using score from 0-3
Results: four teeth from 192 one represent 0 score and 34, 111, 43 teeth represent score 1, 2, 3 respectively before
using super dental floss while 143, 37, 12, 0 represent number of teeth in score 0, 1, 2, 3 respectively after flossing.
When the t-test was applied to test significant between plaque quantity before and after using super floss,a
significant differences were noted.
Conclusion: Patients' instructions to use super dental floss are considered as an important factor for planning good
oral hygiene.
Keywords: super dental floss, oral hygiene, fixed orthodontic appliance. (J Bagh Coll Dentistry 2011;23(3): 109-111).

INTRODUCTION The introduction of fixed orthodontic

The dental plaque seems to occur when the
balance between the microorganisms and the host
is disturbed in some way and this related to the
possible number of virulence factors (1).
Orthodontic therapy may affect the
periodontium by favoring plaque retention and
food debris resulting in gingivitis, by directly
injuring the gingiva as a result of over extended
bands , and by creating excessive and\or
unfavorable forces on supporting tooth
structures.(2) Also it’s particularly difficult to
maintain an acceptable hygiene when bands,wires
and ligatures are involved.(3)
The past two decades have seen greater focus
on dento facial esthetics in the population with an
increasing demand for orthodontic treatment. (4).
Maintaining good oral hygiene is a challenge for
anyone but particularly for orthodontic patients (5),
because of increase in surfaces of teeth and the in
accessibility of some areas of fixed appliance
which make plaque removal more difficult (6). It
has been clear that the orthodontic appliances
contribute to plaque retention and interfere with
the performance of good oral hygiene.(7)
Clinical and experimental studies have
demonstrated that the most important etiological
factor in the inflammatory periodontal diseases is
the presence of bacterial plaque at the level or
below the level of gingival margin.
(1)Assistant Lecturer, Department of Periodontics, College of
Dentistry, University of Baghdad.
appliances into the mouth increases the number of
areas for potential plaque retention, and thus it
will increase the possibility of progressing from a
gingivitis to a periodontitis (8)Personal oral
hygiene is difficult to perform when fixed
orthodontic appliances are in place (9, 10)
Previous studies showed that the placement of
orthodontic appliance in the oral cavity might
result in iatrogenic side effects (11).The appliance
increase the volume of dental plaque and number
of bacteria and their by product may cause higher
incidence in gingival inflammation(12).Recent
clinical studies indicate that the careful plaque
control prevent dental caries , the retention of
food influence by arch wires in fixed appliance
and the roughness of acrylic in removable
appliances (13,14) .
The aim of this study is to evaluate the
changes in the quantity of plaque in patients using
fixed orthodontic appliances by using of super
dental floss.
MATERIALS AND METHODS
The study sample is comprised of 16 patients
wearing fixed orthodontic appliance (7 males and
9 females); with an age range 15–22 years at the
start of orthodontic treatment. They are randomly
selected in private clinic without regard to the
type of malocclusion. No sex discrimination is
included in this study. The exclusion criteria
include the following, no mouth breathing, no
tongue or digit habits, had no abnormal hard or
soft tissue morphology, systemic disease or a

Oral and Maxillofacial Surgery and Periodontology109

J Bagh College Dentistry Vol. 23(3), 2011 Effect of super dental floss

course of antibiotic therapy within the preceding Table 1: The method of scoring, four scores
one month. are used from 0-3.
All patients were treated with fixed Score Represent
orthodontic appliances. Bands were cemented 0 No plaque
with orthophosphate cement to upper and lower Plaque at gingival margin or orthodontic
first molar teeth and rest of teeth were bonded 1
bracket(thin layer)
with composite resin (Alfadent chemical cure Plaque at two area orthodontic bracket and
com-posite resin, ADA) according to 2
gingival margin
manufacturer’s instruction. Plaque at obvious amount in the area between
Oral Hygiene Instruction 3
orthodontic bracket and gingiva margin
Two weeks before appliance construction,
patients and their parents were instructed in Table 2: number of teeth in each scores
conventional oral hygiene using modified Bass before and after flossing
technique. We select the patients who use only No. of teeth Before No. of teeth After
tooth brushing (mechanical) way for oral Score
flossing flossing
hyiegene without any adjuvanit as chlorhexidine 0 4 143
gluconate mouth wash (chemical), fluoride rinses 1 34 37
or gels before or during the study, to exclude their 2 111 12
influence on the quantity of plaque. Beside the 3 43 0
tooth brushing the patient instructed to use super
dental floss once daily after they wear the fixed
Table 3: percentage of teeth according to
appliance.
different scores before and after flossing
Assessment of Oral Hygiene
The quantity of plaque were evaluated after Score Before flossing After flossing
one week when patients wear orthodontic 0 2.083 74.479
appliance then another recording was done after 1 17.708 19.270
one week instruction of using super dental floss, 2 75.812 6.250
figure 1 show the super dental floss. By using 3 22.395 0
disclosing tablets we account the quantity of
plaque. We assessed 12 anterior teeth in each Table 4: comparison of mean before and
patient (6 in each jaw) by using score from 0-3 as after flossing
shown in table 1 Mean Std. deviation p t value
Evaluation of super dental floss benefit was Before flossing 2.0058 0.19260 0.000
7.461
performed according to the criteria of it is After flossing 0.3173 0.17011
properties (oral B laboratories): P<0.0001
Stiffened end to floss under appliances.
Spongy-floss to clean around appliances. DISCUSSION
Regular floss to remove plaque under gingival Many features of oral hygiene have been
line as in figure 1 studied in the literature, The studied patients were
received enormous instructions for oral hygiene
RESULTS performance between and during the treatment
course to give opportunity for continuous
Tables 2 and 3 show the sample description,
motivation throughout the treatment course.
the percentage of scores and numbers of teeth
involved in each scores . The increase in the amount of plaque after
placement of orthodontic appliance was a result of
Four teeth from 192 one represent 0 score and
impaired access to the tooth surfaces with the
34, 111, 43 teeth represent score 1,2,3
respectively before suing super dental floss while tooth brush, so that the effectiveness of plaque
143, 37,12, 0 represent number of teeth in score 0, removal procedures is impaired. Also manual
brushing has a limited effect interproximally;
1, 2, 3 respectively after flossing (table 2).
When the t-test was applied to test significant interdental cleaning remains a problem in
between plaque quantity before and after using orthodontics. The use of single tufted brushes,
dental floss, tooth picks, or other devices demands
super floss, highly significant differences were
excellent patient cooperation and is difficult to
noted, table (4).
perform adequately on a long term basis (15).
During orthodontic treatment with fixed
appliances the effectiveness of plaque removal
procedures is impaired. This can enhance the risk

Oral and Maxillofacial Surgery and Periodontology110

J Bagh College Dentistry
for the development of tooth caries and gingival
inflammation. Furthermore, it has been previously
reported that a slight loss of periodontal support
can be observed following orthodontic treatment
with fixed appliances (16). Recognizing these risks
the orthodontist must make a great effort to
educate patients as regards proper dietary and oral
hygiene habits in an attempt to minimize
detrimental effects on the teeth and periodontal
tissues during orthodontic treatment (17).
During flossing technique practicing and with
the continuous motivation, the patient’s
discomfort had already been overcome, and the
proper flossing became the main aim for the
patients. The patients tried the best to practice
proper oral hygiene and make the oral hygiene
parameters decreased markedly even from the
baseline records. On the other hand, this may be
due to the superiority of the super floss technique
in orthodontic appliance (18). Also the pressure
subjected by the floss bristles on the gingival area
made a massaging affect on the gingival. Upon
patients’ instructions, the patients agreed with the
effectiveness of the using super dental floss for
cleaning bracket (19)
Within the limits of this study it is possible to
conclude that there was significant effect by using
super dental floss in patients wear orthodontics
appliance and decrease the quantity of plaque.
REFERENCES
1. Helfgen EH, Weedeman B, Koeck B. The
intmoralbaukrial colonization of Temponemy
dentric plastic. J Am Dent Assoc 1992;5: 629-32.
2. Carranza Z. Newman m .Clinical Periodontology 10
th Edition. 2008.
3. Anderson G, Bowden G, Raul G. Clinical effects of
CHX mouth rinse on the patients undergoing
orthodontic treatment. Am J Orthod Dontofac Ortho
1997; 111:606-12.
4. Marianne MA, Hom LW. Periodontic and
orthodontic treatment in adults. Am J Orthod
Dentofacial Orthop 2002;122(4): 420-7.
5. Sinclair PM, Berry CW, Bennett CL, Hilton I.
Changes in gingival and gingival flora with bonding
and banding. Angle Orthod 1987;47: 271-8.
Oral and Maxillofacial Surgery and Periodontology111
Vol. 23(3), 2011 Effect of super dental floss
6. Lorri JB, Conniel S. Effective oral hygiene for
orthodontic patients. J Clin Orthod 1990; 315-20.
7. Morris ML. Orthodontic–periodontic relationship.
In: Horowitz SL, Hixon EH. The Nature of
Orthodontic Diagnosis. CV Mosby Co, St Louis.
1966.
8. Zachrisson BU, Alnaes L. Periodontal condition in
orthodontically treated and untreated individuals.
Angle Orthod 1973; 43: 402.
9. Wilcoxon DB, Ackerman RJ, Killoy WJ, Love JW,
Sakumura JS, Tira DE. The effectiveness of a
counter–rotational action power tooth brush on
plaque control in orthodontic patients. Am J Orthod
Dentofac Orthop 1991; 99: 7-14.
10. Balaklicts N, Balaklicts T. Specific microorganisms
isolated from oral cavity of orthodontic patients. Am
J Orthod 1991; 7: 85-98.
11. Balenscifen W, Madonia JV. A study of dental
plaque in orthodontic patients. J Dent Res 1980;
49(2):320-4.
12. Klogstad T, Klonberge M. Effect of orthodontic
treatment on microflora in saliva. J Am Dent Assoc
1984; 95(6): 180-92.
13. Ingerrale B. The influence of orthodontic appliance
on caries frequency. Odontol Revy 1992; 13: 17.
14. AI-Rawi A. The microjlora of dental plaque in acute
gingivitis. Master thesis submitted to the College of
Dentistry, University of Baghdad. 1994
15. Marianne MA, Hom LW. Periodontic and
orthodontic treatment in adults. Am J Orthod
Dentofacial Orthop 2002;122(4): 420-7.
16. Anthony LN, Theodore RH, Harald L, Age A, Hans
B. The natural history of periodontal disease in man.
Risk factors for progression of attachment loss in
individuals receiving no oral health care. J
Periodontol 2001;72:1006-15.
17. Janson G, Bombonatti R, Brandão AG, Henriques
JF, Freitas MR. Comparative radiographic
evaluation of the alveolar bone crest after
orthodontic treatment. Am J Orthod Dentofacial
Orthop 2003; 124: 157-64.
18. Jackson CL. Comparison between electric tooth
brushing and manual tooth brushing with and
without irrigation for oral hygiene of an orthodontic
patient. Am J Ortho1991; 91: 15-20.
19. Jones SC. Tooth brushes and tooth brushing
technique. In: Harris NO, Christen AG. Primary
Preventive Dentistry. 4th ed. Appelton and Lange
Co.: Stanford; 1994: 76-99.
J Bagh College Dentistry Vol. 23(3), 2011 The effect of low-level

The effect of low-level laser on osseointegration of dental

implants
Salah A. Issmaeel B.D.S., H.D.D., F.I.C.M.S. (1)
Ali H. Abbas B.D.S., M.Sc (2)

ABSTRACT
Background: The aim of this study to evaluate the effect of low- level laser on the Osseointegration of dental implant.
Materials and methods: Fourteen patients included in this study that needs dental implants in both sides of the jaw
whether upper or lower jaw. One side of the jaw received dental implant and laser radiation, while the other side
received dental implant only.
Results: Low- level laser application had stimulated Osseointegration, that’s bone formation and maturation around
the implants was improved the site where laser application has been used than that bone around implants without
laser application especially at 4-6 weeks after surgery.
Conclusion: Accelerated bone formation and maturation around the dental implant after application of low- level
laser.
Key words: Dental implant, low- level laser. (J Bagh Coll Dentistry 2011;23(3): 112-116).

INTRODUCTION MATERIALS AND METHODS

There are three types of dental implants: The study was done in the dental implatology
subperiosteal, Transosseous and endosseous center in Al-Karkh general hospital, from March
implants. Endosseous dental implant which is 2006 to May 2007. Fourteen patients (9 males and
used in this study is a device which is surgically 5 females), the patient's age range from 21-38
placed into the jaw bone to replace one or several years old (mean age 29.5 years) included in this
lost roots of the teeth (1). Titanium dental implant study that needs dental implants in both sides of
has suggested as a material of choice for implant the jaw whether upper or lower jaw.
fabrication due to its excellent abrasion and Table 1 reveals the distribution of 34 dental
corrosion resistant, biocompatibility and non toxic implant fixture.
properties(2). The success rate of dental implant
depends on the amount of the osseointegration Table 1: Demographic data
which is a direct bone anchorage to an implant No. of patients 14 patients
body to provide a foundation to support prosthesis 21-38 years ( mean age 29.5
Age
and to transmit occlusal forces directly to the years)
bone(3). There are many factors affecting the Sex
9 males (64.28 %)
osseointegration as: characteristic of the material, 5 females (35.72%)
design of the fixture, bone quality, surgical No. of fixtures 34 implant fixtures
technique and the implant loading conditions 6 implant fixtures in the
(4) anterior area
.There are many methods applied to stimulate
the osseointegration to achieve excellent implant- Distribution of 24 implant fixtures in the
bone bond for stable and fixed implant. Many fixtures premolar area
studies done on low energy laser and stated that 4 implant fixtures in the molar
area
has a biostimulation mechanism that’s used for
In anterior area use:
acceleration of soft tissue and bone healing
(5,6) (Length 13, 15, 18 mm,
.The aim of this study is to evaluate the effect
diameter 3.8, 4.5, 5.5).
of low energy 904 nm diode laser on the In premolar area use:
Lengths and
osseointegration of titanium dental implants. diameters (Length 10, 11, 12 mm,
of fixtures diameter 3.25, 3.8, 4, 4.5, 5.5,6).
In molar area use:
(Length 8 mm, diameter 3.75,
4.5, 5.5).

All patients were examined under dental

(1)Head of Department of Oral and Maxillofacial Surgery.
Al-Karkh General Hospital.
(2)Lecturer, Department of Oral and Maxillofacial Surgery.
College of Dentistry, University of Baghdad.
implantology committee for restoring the lost
tooth or teeth by dental implants. All the patients
in this study have good health condition and
without any systemic disease. The surgical
operation done under local anesthesia, by same

Oral and Maxillofacial Surgery and Periodontology112

J Bagh College Dentistry Vol. 23(3), 2011
oral surgeon and all patients were given
antibiotics postoperatively. The surgical
procedure done by reflection of three-sided flap
with slight curvature lingually or palatally from
the crest of the alveolar ridge, then do drilling of
the sockets in steps.
One side of the patients jaw received dental
implants with laser application, the laser
irradiation done in this manner; two minutes to
the prepared socket prior to implantation, another
two minutes after implant insertion in the bone
and finally another two minutes of laser
irradiation to the soft tissue covering the dental
implant after suturing of the flap.
The other side of the same patient's jaw received
dental implants using the same surgical procedure
but without laser application.
Intra oral periapical and extra oral
orthopantamograph x- ray films were taken for
each patient for evaluation preoperatively and
postoperatively (four weeks and six weeks).
The laser equipment used in this study was
Optodent unit (figure1), the laser emission is low
energy infra red gallium – arsenide (Ga-As) laser,
wave length 904 nm, using continuous beam of
radiation, average power is 5 mw, focal spot of
5.1 mm.
Figure 1: Optodent unit
The implant kits used in this study was Oral
Tronics and Friadent implant (figure2).
Figure 2: FRIADENT Implant kit
RESULTS
A total number of patients in this study were
fourteen; each one of them had implantation
surgery with laser application on one side of the
jaw and implantation surgery without laser
application on the other side of the same jaw.
Oral and Maxillofacial Surgery and Periodontology113
The effect of low-level
Almost the patients included in this study have
reduction in pain and edema after surgical
procedure of implantation of the laser irradiated
side in comparism with the other side where
surgical implantation without laser application.
In this study we depend on the x-ray for the
evaluation of the amount of reparative bone by its
radio opacity around the implants in laser
irradiated side and compare it with the radio
opacity of the bone around the implants in the non
irradiated side of the same patient's jaw.
The radiographs for the evaluation taken at
intervals:
There is no difference in radio opacity of bone
around the implants immediately after operation
in both sides of the jaw (one side with laser
radiation and the other side without laser
radiation).
There is a slightly increase in radioopacity around
the implant in laser radiated side in comparism to
the non radiated side after four weeks (figure3, 4
& 5).
Figure 3: Four weeks postoperatively, right
side with laser application, left side without
laser application.
Figure 4: Four weeks postoperatively, right
site without laser application, left side with
laser application.
J Bagh College Dentistry Vol. 23(3), 2011 The effect of low-level

A
A

B
Figure 5: Four weeks postoperatively (the B
same patient of figure 4), (A) without laser Figure 7: six weeks postoperatively (the same
application, (B) with laser application. patient of figure 6), (A) with laser
application, (B) without laser application.
After six weeks there is a marked increase in the
bone radio opacity around the implant in laser
radiated side in comparism to the other side
(figure 6, 7, 8 &9).

Figure 6: Six weeks postoperatively, right Figure 8: six weeks postoperatively, right
side with laser application, left side without side without laser application, left side with
laser application. laser application.

Oral and Maxillofacial Surgery and Periodontology114

J Bagh College Dentistry Vol. 23(3), 2011
A clinical mobility test as proposed by several
B is reasonable to assume that a similar period as for
Figure 9: six weeks postoperatively (the same
patient of figure 8), (A) without laser
application, (B) with laser application.
A time, these results in agreement with other studies
B who reported the influence of low energy laser
Figure10: Four weeks after laser application
(A), six weeks after laser application (B)
There is a slight increase in radio opacity around
the implants from four weeks to six weeks in laser
radiated implants (figure10).
Oral and Maxillofacial Surgery and Periodontology115
The effect of low-level
There is a slight increase in radio opacity around
the implants from four weeks to six weeks in laser
radiated implants (figure10).
DISCUSSION
Many methods have been tried to demonstrate
clinically osseointegration of an implanted
material, these tests have been used to indicate,
not verify osseointegration, which is a concept
defined at the histological level, performing a
authors, and finding implant mobility is definite
evidence that it is not integrated(7).
Success osseointegration is highly dependent on
minimum surgical trauma and avoid thermal
damage to the bone by using slow drilling speed,
the use of successive incrementally large sharp
drills and copious saline irrigation aims to keep
the temperature below that at which bone tissue
damage occurs (a round 47cº for 1 min.) (8, 9).
Low energy laser therapy had been reported to
reduce the period for bone fracture healing (10). It
fracture healing is required for the bone
surrounding the implant for healing because it
should be mechanically strong enough to resist
unlimited masticatory forces, thus it appears that
the use of continuous beam of laser with a wave
length 904 nm applied directly over the site of
implantation for two minutes and for three session
intervals found to increase the bone formation
around the dental implants and had become
mature in a short period of time than that around
the non irradiated dental implants (11,12).
The results indicate that low level laser
application had stimulated bone formation and
therefore bone become mature in shorter period of
(13, 14)
.
The early bone maturation could be attributed to
the stimulation of fibroblasts proliferation through
the application of low level laser therapy (15).
Thus the laser irradiated implants wound be able
to withstand loading after a short healing period
because the time required for the process of
osseointegration to develop around titanium
implants was reduced(5).
The reduction in pain and edema of short term
follow up as in agreement with other studies (16, 17)
therapy on pain, swelling and healing after oral
implantation and surgical removal of impacted
mandibular third molar.
J Bagh College Dentistry Vol. 23(3), 2011 The effect of low-level

palate suture during expantion in the rats. Am Ortho

REFERENCES Dento-technical Orthop 1997; 111 (5) 525-32.
1. Anusaivce KJ. Dental implants; Philips science of
11. Thabat Hussain, A. Jawad. Effect of low laser
the dental material. 10th ed., W.B. Saunders 1996;
level diode laser on the integration of intraosseous
656.
dental implants. Thesis,institute of laser, University
2. Branmark PI. Osseointegration titanium implants.
of Baghdad 2006.
Acta orthopscad 1988; 57:285.
12. Mohammed AH, Ahlam H. Effect of 904 nm
3. Sumign hoho, Eijichda. Osseointegration occlusal
diode laser with different exposure times on the
rehabilitation. 1989 Quintessence publishing co.ltd;
titanium dental implants inserted in rabbit's tibia;
p12.
2006.
4. Albrekttson T. Direct bone anchorage of the dental
13. Jawad N, Twaij MA, Mohammed IFR. Efficacy of
implant. J Prosthet Dent 1983; 50 (2):225-61.
irradiation with low level laser on the healing of the
5. Mohammed HR, Younis NA, Al-Talabani NG.
fractures pan. J Ortho Trauma 2001; Jan 5(1): 95-
Pathological study of osseointegration around
106.
titanium implant post H.H.H. Irq. J Oral and Dental
14. Takeda Y. Irradiation effect of low energy laser on
Science 2003;.2 (1)19.
alveolar bone after tooth extraction. J. Oral &
6. Hortbudak O, Mailath Pokorny G. Biostimulation
Maxillofacial surg 1988;17:338-9.
of the bone marrow cells with a diode soft laser. Clini
15. Chommette G, Auro R, Zeitoum R, Mowsquest.
Oral Implants Res 2000; 11 (6): 540-5
The effect of low- level laser therapy on the gingival
7. Lekholim AR, Branemark RB. A 15 years study
fibroblast using histoenzymological & electron
of osseointegrated implants in the treatment of
microscope measuring techniques. J Biol Buccale
edentulous jaw. Int J Surg 1981;10 (6):387- 416.
1987; 15:215-49.
8. Branner R, Hania Ladthaler M, Braun Fulco O.
16. Alashkar Sh Badram. Clinical comparison
Application of the laser light of low power density,
between Ga-Al-As laser and drug therapy during oral
clinical & experimental investigation. Curr Prob
implantation. Damascus University Faculty of dental
Derm 1981; (5) 111-6.
medicine 2005.
9. Kaigler D, Lang BR. The bone chamber an
17. Al-hussaini AH. Evaluation of the effect of low-
improved method of the collection tissue. Int J Oral
energy laser on the incidence of dry socket
Maxillofacial Implants 1989; 4: 183-90.
"comparative study". Thesis, College of Dentistry,
10. Saito S, Shimizu N. Stimulatory of low power
University of Baghdad; 1992
laser irradiation on the bone regeneration in mild

Oral and Maxillofacial Surgery and Periodontology116

J Bagh College Dentistry Vol. 23(3), 2011 Caries experience of the

Caries experience of the first permanent molars among a

group of children attending Pedodontics' Clinic College of
Dentistry
Ahlam T. Mohammed B.D.S., M.Sc.(1)

ABSTRACT
Background: First permanent molars are very important teeth and they have the highest caries attack rate among
the permanent dentition. This study was designed to investigate the mortality and severity of caries as well as
treatment needs in the first permanent molars.
Materials and methods: The sample composed of 92 children aged 6-12 years old. Caries experience and treatment
needs were measured by using dental mirror and sickle shape probe.
Results: 14. 1% of children were caries free. DMFT and DMFS were increased with age. DT was the major part of DMFT.
About 47% of the total sample needed one surface restoration.
Conclusion: First permanent molars have a high caries experience and more care should be given to conserve them
by fissure sealing or by prompt treatment of early lesions.
Keyword: Caries, permanent first molars, children. (J Bagh Coll Dentistry 2011;23(3): 117-119).

INTRODUCTION
The permanent first molars were more
susceptible to dental caries and they have the
highest caries attack rate among the permanent
dentition (1). This might attributed to their early
eruption in the oral cavity (2) and also due to their
deep fissures (3).
Due to the importance of these teeth in the
dentition, as their loss may lead to undesirable
effects on the occlusion(4) so every effort should
be made to restore them in the oral cavity.
Although many Iraqi studies were conducted
concerning caries experience in first permanent
molars (5,6,7,8) but we still need more information
related to this subject.Therefore this study was
conducted to investigate the mortality and severity
of dental caries as well as treatment needs in the
first permanent molars among a group of children
in Baghdad City.
MATERIALS AND METHODS
The sample composed of 92 children with an
age of 6-12 years . Those children were attending
the dental clinic in the College of Dentistry,
Baghdad University. Dental examination and
diagnosis of dental caries were done by using
dental mirror (No. 4) and sickle shape probes
(No.00) according to the criteria of WHO (9) for
assessment of caries experience and treatment
needs When the child not has any decayed,
missed or filled tooth was recorded as caries free.
Statistical analysis was done by using Student's t-
test at a level of significance of 5%.
(1) Assistant Professor, Department of Pedodontics and
Preventive Dentistry, College of Dentistry, University of Baghdad
RESULTS
Table 1 illustrates the percentage of caries
free children by age and gender. Table 2 shows
the caries experience of the first permanent
molars. Values of decayed teeth (DT), missing
teeth (MT) and filled teeth (FT) were found to
increase with advancing age, these were
statistically not significant for DT and MT
(P>0.05) but it was significant for FT (P<0.05).
DT component constitutes the major part of the
DMFT for both age groups. The means of DMFT
and DMFS were significantly higher at age 10-12
years than age 6-9 years (P<0.05), that is to say
both of them were increased with age. Although
total males had a higher DT than total females but
the difference was not significant (P>0.05).
Table 3 presented the treatment needs for the
first permanent molars. The highest percentage of
teeth as about 47% needed one surface filling and
12.1% needed two surface filling while 0.3%
needed pulp treatment.
DISCUSSION
This study found that the rate of caries free
children was lower than that found in other study
in Baghdad city (6).While it was much lower than
that reported by other investigation in rural area (7,
8)
. This lower rate may be attributed to that caries
experience among rural children is lower than in
urban children (10, 11) which may be due to the
difference in the dietary habits between the two
communities, as higher sugar consumption in
urban compared to rural areas.
Finding of this investigation clearly shows
that the mean decayed tooth (DT) for age (10-12)
years was higher than that for age (6-9) years, the
same finding for missing tooth (MT) and filling

Orthodontics, Pedodontics and Preventive Dentistry117

J Bagh College Dentistry Vol. 23(3), 2011 Caries experience of the

tooth (FT) this may be due to the fact that dental
caries increases with age and this comes in
agreement with many previous studies(7,8). Result
of the present study also revealed that the means
of DMFT and DMFS were found to increase with
advancing age, this agrees with previous
studies(6,7) and may be attributed to the fact that
dental caries is chronic and incremental
disease(12).
DT was found to be constitutes the major part
of DMFT for both age groups and for both
genders. This may reflect a negative attitude
towards dental treatment and it comes in
accordance with other studies (7, 8).
Most of the teeth in this investigation needed
one surface filling (47%), this rate was
approximate to that found in previous study(7) and
(12.1%) needed two surface filling, while not a
single tooth in the studied sample was needing
extraction. That is to say most treatment
demanded in this study was the one surface
filling, this comes in agreement with previous
study(7) and in disagreement with other(13). Data of
the present study clearly shows the importance of
improving the dental knowledge and attitude of
the children and their parents which may not
actually aware of dental health status of their
children, so preventive programs are needed in
our country to improve the dental health of Iraqi
children.
REFERENCES
1. Lo ECM, Evans RW, Lind OP. Dental caries status
and treatment needs of the permanent dentition of 6-
12 years olds in Hong Kong. Comm Dent Oral Epid
1990; 18: 9-11.
2. Al-Farhan SA. Aspect of dental health in Iraq. Master
thesis submitted to the College of Dentistry,
University of Dundee, 1979.
3. Carvalho JC, Thylstrup A, Ekstrand KR. Results of 3
years of non-operative occlusal Caries treatment of
erupting permament first molars. Comm Dent Oral
Epid 1992; 20: 187-92.
4. Al- Sahaf NH. The prevalence of extracted first
permanent molars in Baghdad, Iraq. J College of
Dent 1998; 3: 61- 73.
5. Ghose L, Baghdadi V. Severity of caries attack in the
permanent first molars. J Iraqi Dent Res 1981; 2.
6. Baghdadi VS, Ghose LJ. Comparison of the severity
of caries attack in permanent first molar in Iraqi and
Sudanese school children. Comm Dent Oral Epid
1979; 7: 346-8.
7. Al-Sayyab M, Al-Alousi W, El-Samarrai S. Mortality
of first permanent molars among Iraqi children living
in two Iraqi villages (Sheha, Al-Buetha). J College of
Dent 1995; 261-5.
8. Zaki M. Morality of first permanent molars among
chlidren in El-Edwania village-Iraq. Iraqi Dent J
1996; 29: 35-9.
9. WHO. Oral health surveys. Basic methods, WHO,
Geneva, Switzerland. 1987.
10. Bratthal D, Serinirach R, Carlsson P, Lekfuagfu S.
Streptococcus Mutans and dental caries in urban and
rural school children in Thailand. Comm Dent Oral
Epid 1986; 14: 274-6.
11. Al-Sayyab M. Oral health status among 15 year old
school children in the central region of Iraq. Master
thesis, Baghdad University, 1989.
12. Mc Donald RE, Avery DR. Dental caries in child and
adolescent. In Dentistry for the child and adolescent.
Edt. By Mc Donald RE and Avery DR, 5th edt., St.
Louis, CV Mosby Co. 1987; 219–63.
13. Sulaiman A, Zaki M. Caries experience among
children in Al-Edwania village, Baghdad. Iraq Dent J
2002; 30: 147.

Table 1: Distribution of children by age and gender

Age group No. of No. of Caries free
Gender
(in year) child Teeth (6s) No. %
M 18 71 5 27.8
6-9 F 24 93 4 16.7
Total 42 164 9 21.4
M 31 124 3 9.7
10-12 F 19 76 1 5.3
Total 50 190 4 8.7
M 49 195 8 16.3
All F 43 169 5 11.6
Total 92 364 13 14.1

Orthodontics, Pedodontics and Preventive Dentistry118

J Bagh College Dentistry Vol. 23(3), 2011 Caries experience of the

Table 2: Caries experience of first permanent molars among children by age and gender
Age DT MT FT DMFT DMFS
Group Gender
Mean ± SD Mean ± SD Mean ± SD Mean ± SD Mean ± SD
(in year)
M 2.00 1.68 0 0 0.22 0.54 2.22 1.69 2.22 1.69
6-9 F 2.25 1.56 0 0 0.29 0.75 2.54 1.58 3.20 2.39
Total 2.14 1.60 0 0 0.26 0.66 2.40 1.62 2.78 2.15
M 2.64 1.47 0 0 0.67 1.16 3.32 1.30 4.64 2.38
10-12 F 2.47 1.21 0.05 0.2 0.84 1.11 3.36 1.11 4.36 3.26
Total 2.58 1.37 0.02 4 0.74 0.13 3.34 1.22 4.54 2.72
M 2.40 1.56 0 0 0.51 1 2.91 1.53 3.75 2.44
All F 2.34 1.41 0.02 5 0.53 0.95 2.90 1.44 3.72 2.83
Total 2.38 1.48 0.01 0.01 0.52 0.97 2.91 1.48 3.73 2.62

Table 3: Treatment needs for the first permanent molars

One Three
Age No. of Two surface Pulp
Surface Surface Extraction
Group Gender Teeth filling treatment
filling filling
(in year) (6 s)
No % No % No % No % No %
M 71 35 49.3 1 1.4 0 0 0 0 0 0
6-9 F 93 41 44.1 13 14 0 0 0 0 0 0
Total 164 76 46.3 14 8.5 0 0 0 0 0 0
M 124 55 44.4 26 21 0 0 1 0.8 0 0
10-12 F 76 40 52.6 4 5.3 3 3.9 0 0 0 0
Total 190 95 50 30 15.8 3 1.6 1 0.5 0 0
M 195 90 46.6 27 13.8 0 0 1 0.5 0 0
All F 169 81 47.9 17 10.1 3 1.8 0 0 0 0
Total 364 171 47 44 12.1 3 0.8 0 0.3 0 0

Orthodontics, Pedodontics and Preventive Dentistry119

J Bagh College Dentistry Vol. 23(3), 2011 Oral hygiene and salivary

Oral hygiene and salivary immunoglobulin among acute

lymphocytic leukemic patients undergoing chemotherapy
courses
Nadia A. Al-Rawi B.D.S., M.Sc., Ph.D (1)

ABSTRACT
Background: Chemotherapy impaired the normal function of the human immune system. The patients' ability to
accomplish adequate oral hygiene may be limited. When chemotherapy is indicated, it is imperative that health of
the oral cavity be assessed initially as well as throughout therapy. This study was conducted to evaluate the oral
hygiene and salivary immunoglobulin in patients undergoing chemotherapy courses.
Subjects and methods: The study groups included 30 acute lymphatic patients, they were under chemotherapy. The
control group includes 30 subjects matching with study group in age and gender. Plaque status was evaluated
according to the Silness &Loe Index, dental calculus according to Ramfjord index, while gingival condition was
assessed according to Loe & Silness. After oral examination, stimulated saliva samples were collected from the subjects
and performed under standard condition following instruction cited by Tenovuo & Lagerlof, and chemically analyzed
for the detection of salivary immunoglobulin (IgA & IgG).
Results: Higher plaque, calculus and gingival index were recorded among acute lymphatic patients compare to the
control group, statistically significant difference with calculus index between groups. A low level of IgA, and IgG were
seen among the study group compared to the control groups in both genders. A non-significant correlation was
found between salivary immunoglobulin and oral cleanliness among acute lymphatic patients.
Conclusions: Salivary immunoglobulin levels affect severally by chemotherapy. Salivary IgA, and IgG defect seem to
play a role in the development of poor oral hygiene among acute lymphatic patients.
Key words: Oral health, salivary immunoglobulin, chemotherapy. (J Bagh Coll Dentistry 2011;23(3): 120-123).

INTRODUCTION
Approximately one million people develop
invasive cancer each year. Of these, 40% receive
curative benefit from surgery, radiation,
chemotherapy, or a combination modality (1). In
dealing with patients with cancer a team approach
is required for effective management (2). When
chemo therapy is indicated, it is imperative that
health of the oral cavity be assessed initially as
well as throughout therapy. Oral complications
can affect the patient's tolerance to chemotherapy
and quality of life. Pre therapy dental evaluation
can decrease the incidence and severity of these
complications (3). Chemotherapy may permanently
alter the quality and quantity of saliva. Saliva
plays an important role in the maintenance of oral
health. One of the major functions of saliva is to
protect the oral tissues against pathogens by
immunologic means. The most important
immunoglobulin in saliva are IgA and IgG. The
mean source of IgG in saliva is the crevicular
pocket fluid. Secretary IgA is mostly synthesized
in the minor salivary glands (4,5)
Immunoglobulin can inactivate bacteria through
the inhibition of bacterial metabolism and
attachment to oral tissues as well as aggregation
of microorganisms. Gingival inflammation can
cause an increase of salivary immunoglobulin (6,7).
Correlation between IgA levels and dental
diseases has been studied with conflicting results
(8-14).
Chemotherapy impaired the normal function
of the human immune system (15). It can cause
major alteration in the oral defense mechanisms
that are likely to play a role in the increased
susceptibility to oral diseases in human (16-18).
The patients' ability to accomplish adequate
oral hygiene may be limited. When chemotherapy
is indicated, it is imperative that health of the oral
cavity be assessed initially as well as throughout
therapy (19-21). This stud aimed to evaluate the
oral hygiene and salivary immunoglobulin (IgA &
IgG), in acute lymphocytic leukemic patients
undergoing chemotherapy courses, in comparison
to control group matching with age and gender.

PATIENTS AND METHODS

(1) Department of Pedodontics and Preventive Dentistry, College
of Dentistry, University of Baghdad
The study groups included 30 patients, they
were under chemotherapy, (clinically examined at
the National Centre of Hematology and Scientific
Research of Al – Yarmook Hospital) aged 25-35
years old of both gender, the patients were
selected according to the duration of the treatment
with chemotherapy (from 6 month – 2 years) and

Orthodontics, Pedodontics and Preventive Dentistry120

J Bagh College Dentistry Vol. 23(3), 2011
according to the type of the disease (acute
lymphocytic leukemia (ALL)). Sample collection
was started at beginning of March 2011 till
beginning of April 2011. The control group
includes 30 subjects, they have no history of any
systemic problem from questionnaire, matching
with study group by age and gender, and they
were selected from the same geographical area of
the center. Plaque status was evaluated according
to the Silness &Loe Index (22), dental calculus
according to Ramfjord index (23), while gingival
condition was assessed according to Loe &
Silness(24). After oral examination, stimulated
saliva samples were collected from the subjects
(study & control groups) and performed under
standard condition following instruction cited by
Tenovuo & Lagerlof (25), and chemically analyzed
for the detection of salivary immunoglobulin (IgA
& IgG) (26). Data processing and analysis were
carried out using SPSS (version 12).
RESULTS
Table 1 show that oral health variables
Plaque Index (PlI), Calculus Index (CalI) and
Gingival Index (GI), among acute lymphatic
group and control group. It is clear from the
table, which illustrate the wide differences
between both study and control groups in the
levels of all oral hygiene indices. It was found
that mean of Plaque index (PI) higher and
record double value among acute lymphatic group
compare to the control group, but statistically
difference failed to reach significance between
both groups p=0.050
In regarding to calculus index (CalI) data
analysis show that also more than twice in the
index has been recorded among acute lymphatic
group compare to the control group, and statically
significant difference between groups p=0.012.
Concerning mean of gingival index (GI) the
same table show that high index among group
who were under chemotherapy treatment compare
to the control group, with no significant
difference.
Table 2 illustrates salivary immunoglobulin
levels among study and control groups. Low
levels were illustrated of both IgA & IgG among
acute lymphocytic leukemic patients compare to
the control subject. Differences were statistically
highly significant between both groups.
Table 3 shows correlation between PlI,
CalI, and GI with salivary immunoglobulin IgA
concentration. Positive correlations were obtained
between salivary IgA and all oral variables among
group who were under chemotherapy treatment,
but no significant statistically, while negative
Orthodontics, Pedodontics and Preventive Dentistry121
Oral hygiene and salivary
significant correlation among control group in
relation to gingival index.
Table 4 shows correlation between PlI, CalI,
and GI with immunoglobulin IgG concentration in
saliva. Among acute lymphocytic group, positive
correlations were recorded in this study between
IgG in saliva with plaque and calculus index,
while negative correlation with gingival index.
These correlations statistically failed to be
significant.
In regarding to control group, no significant
correlations could be found among them with all
oral variables.
DISCUSSION
Saliva plays an important role in the
maintenance of oral health. One of the major
functions of saliva is to protect the oral tissues
against pathogens by immunologic means. The
most important immunoglobulins in saliva are
IgA and IgG. The main source of IgG in saliva is
the crevicular pocket fluid (4,5). Gingival
inflammation can cause an increase of salivary
immunoglobulins (6,7). In this study it was shown
that patient who received chemotherapy have a
low level of IgA compared with healthy group,
this could be the result of degenerative changes of
the minor salivary glands ( decrease in flow rate),
or an inhibitory effect on the cells that produce the
immunoglobulins or on the transport mechanism
(27)
. Serum-derived molecules, such as IgG, have
been found in saliva in this study in low level
among patient under chemotherapy courses, in
spite of the fact that IgG increase with gingival
inflammation as a result of leakage of these
components into the oral cavity because of the
loss of the barrier function of the epithelium (16),
this low level among acute lymphatic patient as a
result of impairing the normal function of the
human immune system by chemotherapy which
can cause major alterations in the oral defense
mechanisms that are likely to play a role in the
decrease of salivary contents of immunoglobulins
(5)
Although the relationship was clearly
positive between salivary IgA and all oral
variables among group who were under
chemotherapy treatment, but statistically with no
significant, this result may be related to the wide
variation in this salivary immunoglobulin which
illustrated from a high standard deviation among
them. Also positive correlations were recorded in
this study between IgG in saliva with both plaque
and calculus index among acute lymphocytic
group, but statistically failed to reach significance,
while negative correlation with gingival index
among the same group . This negative relationship
with GI indicate that the high effect of
J Bagh College Dentistry Vol. 23(3), 2011 Oral hygiene and salivary

chemotherapy can inactivate the normal function
of human immune system among this type of
patients (15)
Early dental intervention may significantly
reduce oral complications associated with
myelosuppressive cancer treatment in
lymphocytic leukemic patients. It is therefore
crucial to evaluate the oral health surveys and to
eliminate potential sources of infection in mouth
among these patients concurrent with their
medical therapy.
REFERENCES
1. Pritchard-Jones K, Kaatsch P, Steliarova-Foucher E.
et al. Cancer in children and adolescents in Europe:
Developments over 20 years and future challenges.
Eur J Cancer 2006; 42: 2183–90.
2. Oeffinger KC, Hudson MM. Long-term
complications following childhood and adolescent
cancer: Foundations for providing risk based health
care for survivors. CA Cancer J Clin 2004; 54:208-
36.
3. DePaola LG, Peterson DE, Overholser CD Jr, Suzuki
JB, Minah GB, Williams LT, Stansbury DM, Niehaus
CS. Dental care for patients receiving chemotherapy.
J Am Dent Assoc 1986; 112:198-203.
4. Parslow T, Staties D, Terr A, Imboden J. Medical
immunology. Lange medical book/ McGraw-Hill
Medical Publishing division. 10th ed. 2001.
5. Goldsby R. Kindt T, Osborne B. Kuby Immunology.
W. H. Ferrman and Company N.Y. 2000.
6. Rantonen P. Salivary flow and composition in
healthy and diseased adult, Academic dissertation,
Faculty of Medicine, University of Helsinki, Finland
2003; 67-70.
7. Lindstom FD. Salivary IgA in periodontal disease.
Acta Odontol Scand 1973; 31: 31-7.
8. Berglund SE. Immunoglobulin in human gingival
with specificity for oral bacteria. J Periodontol 1971;
42: 546-50.
9. Challacombe SJ. Immunoglobulin in paroted saliva
and serum in relation to dental caries in man. Caries
Res 1976; 165-77.
10. Everhart DL, Girgsdy WR, Carter WH. Evaluation of
dental caries experience and salivary
immunoglobulin in whole saliva. J Dent Res 1972;
51: 1487-91.
11. Everhart DL, Klapper B, Carter WH, Moss S.
Evaluation of dental caries experience and salivary
immunoglobulin IgA in children. Caries Res 1972;
11: 211-5.
12. Loesche W. Role of streptococcus mutans in human
dental decay. Microbiol Rev 1986; 50: 353-80.
13. Parveenkumor, Michael Clarck. Clinical medicine
fifth edition, Mc grow hill 2002.
14. Pekovic D, Adamkievicz V, Gornitsky M.
Immunoglobulin in human dental caries. Arch Oral
Biol 1988; 33: 135-40.
15. Rivier G, Papagiannoulis L. Antibodies to
indogenous and laboratory strains of streptococcus
mutanus in saliva . Pediatric Dent 1987; 9: 216-20.
16. Pajari U, Poikonen K, Larmas M, Lanning M.
Salivary immuonoglobulin, lyzozome, pH, and
microbial counts in children receving anti- neoplastic
therapy. Scand J Dent Res 1989; 97: 171-7.
17. Gentle TA, Warnock DW, Eden OB. Prevalence of
oral colonization with Candida albicans and anti-C.
albicans IgA in the saliva of normal children and
children with acute lymphoblastic leukaemia.
Mycopathologia 1982; 87: 111-4.
18. Mansson-Rahemtulla B, Techanitiswad T,
Rahemtulla E, et al. Analysis of salivary components
in leukemia patients receving chemotherapy. Oral
Surg Oral Med Oral Pathol 1992; 73: 35-46.
19. Peterson DE, Minah GE, Overholser CD, Suzuki JB,
DePaolo LG, Stansbury DM, Williams LT, Schimpff
SC. Microbiology of acute periodontal infection in
myelosuppressed cancer patients. J Clin Oncol 1987;
5: 1461-8.
20. Sixou JL, De Mederios-Batista O, Gandemer V,
Bonnaure-Mallet M. The effect of chemotherapy on
the supragingival plaque of pediatric cancer patients.
Oral Oncol 1998; 34 (6):476-83.
21. Peterson DE, Minah GE, Overholser CD, Suzuki JB,
DePaolo LG, Stansbury DM, Williams LT, Schimpff
SC. Microbiology of acute periodontal infection in
myelosuppressed cancer patients. J Clin Oncol 1987;
5: 1461-8.
22. Silness J, Loe H. Periodontal disease in pregnancy ∏.
Acta Odontol Scand 1964, 24, 747-59.
23. Ramfjord SP. Indices for prevalence and incidence of
periodontal disease. J Periodontol 1959; 30:51-9.
24. Loe H, Silness J. Periodontal disease in pregnancy 1.
Acta Odontol Scand 1963, 21, 533-51.
25. Tenovuo J, Lagerlof F. Saliva in: Thyistrup and
Fejerskoy, textbook of clinical cariology. 2nd ed.
Munksgaard. Coppnhagen 1996.
26. Mancini G, Carbonara AO, Heremans JF.
Immunochemical quantitation of antigens by single
radial immunodiffusion in. Immunocjemistry 1965;
2: 235-9 (Cited by Goodman and Parslow, 1994).
27. Main BE, Calman KC, Fergason MM, et al. The
effect of cytotoxic therapy on saliva and oral flora.
Oral Surg Oral Med Oral Pathol 1984; 58:545-8.

Table 1: Plaque Index (PlI), Calculus Index (CalI), and Gingival Index (GI) mean and standard
deviation (M±SD) among acute lymphatic leukemic group and control groups
Acute lymphatic group Control group Statistical difference
Variable
No. (M±SD) No. (M±SD) t-test df p-value
PI 30 2.09±.64 30 1.18±.50 6.113 58 .050
CalI 30 2.11±.96 30 1.04±.60 5.141 58 .012*
GI 30 2.50±.60 30 1.21±.68 7.735 58 .782
*Significant

Orthodontics, Pedodontics and Preventive Dentistry122

J Bagh College Dentistry Vol. 23(3), 2011 Oral hygiene and salivary

Table 2: Salivary immunoglobulin levels (IgA and IgG), mean and standard deviation (M±SD)
among acute lymphocytic leukemic group and control groups
Variable Acute lymphatic group Control group Statistical difference
(mg/ dl ) No. (M±SD) No. (M±SD) t-test df p-value
IgA 30 60.85±46.11 30 194.92±86.30 -7.505 58 .000**
IgG 30 236.78±130.05 30 784.16±380.78 -7.451 58 .000**
** Highly significant

Table 3: Correlation between Plaque Index (PlI), Calculus Index (CalI) and Gingival Index (GI),
with IgA among acute lymphatic leukemic group and control groups
PlI CalI GI
Groups
r p-value r p-value r p-value
Acute lymphocytic leukemia .076 .689 .097 .610 .122 .520
Control -.165 .383 -.104 .583 -.409 .025*
*Significant

Table 4: Correlation between Plaque Index (PlI), Calculus Index (CalI) and Gingival Index (GI)
with IgG among acute lymphatic leukemic group and control groups
PlI CalI GI
Groups
r p-value r p- value r p- value
Acute lymphocytic leukemia .247 .188 .338 .050 -.009 .962
Control .088 .642 -.044 .819 -.258 .169

Orthodontics, Pedodontics and Preventive Dentistry123

J Bagh College Dentistry Vol. 23(3), 2011 Enamel defects in relation

Enamel defects in relation to nutritional status among a

group of children with congenital heart disease
(Ventricular septal defect)
Nidaa O. AL-Etbi B .D. S, M .Sc.(1)
Wael S. Al-Alousi B. D. S., M. D. Sc.(2)

ABSTRACT
Background: Congenital heart disease is a structural anomaly of the heart or great vessels, that is or could be of
functional significance. Children with congenital heart disease are at a high risk to develop oral diseases. The aim of
this study was to investigate the percentage of occurrence and severity of the enamel defects in relation to the
nutritional status among a group of children with ventricular septal defect compared to control group matching with
age and gender.
Materials and methods: A sample of 60 pediatric patients with ventricular septal defect (study group) and 30 normal
healthy children (control group), their ages range between (5-8) years old were examined. The study group was
divided into two subgroups according to the medication (with medication ventricular septal defect and without
medication ventricular septal defect groups). Clinical examinations were conducted under standardized conditions.
Enamel defects were diagnosed and recorded following the criteria of World Health Organization (1). The assessment
of nutritional status was performed by using anthropometric measurement (body mass index) following the Centers
for Disease Control and Prevention growth chart (2).
Results: Results revealed that a higher percentage of children with enamel defects were recorded among with
medication ventricular septal defect group 80%, without medication ventricular septal defect group 63.3%
compared to13.3% in the control group. For the primary teeth, hypoplasia was the most distributed type of enamel
defects among ventricular septal defect groups. While among the control group, demarcated opacities were the
most prevalent type for both dentition. The enamel hypoplasia for primary and permanent teeth showed higher
mean value among malnourished children compared to well nourished among both ventricular septal defect
groups with statistically no significant difference.
Conclusions: Children with ventricular septal defect had a high enamel defects compared to the control children.
Key words: Septal defect, nutrition, hypoplasia. (J Bagh Coll Dentistry 2011;23(3): 124-129).

INTRODUCTION
Children with congenital heart disease
commonly experience delayed growth. The
severity of growth disturbance depend on the
anatomical lesion and its functional effect, most
children with mild defects grow normally.
However, weight gain is commonly slower than
normal (3). the mechanisms of growth
interference have implicated malnutrition as a
result of anorexia and inadequate nutrient and
caloric intake, hyper metabolic state, academia
and cation imbalance, tissue hypoxemia,
diminished peripheral blood flow, chronic
cardiac decompensation, malabsorption or
protein loss, and recurrent respiratory infection
(4, 5)
. Studies comparing growth and development
of these children generally found that they have
decreased height and weight (6)
One study reported that, among patients with
ventricular septal defect, the size of the left-to-
right shunt and the abnormal hemodynamic in
the pulmonary circulation are important factors
in the etiology of impaired growth.
(1) MSc student Department of Preventive Dentistry, College of
Dentistry. University of Baghdad
(2) Professor Department of Preventive Dentistry, College of
Dentistry. University of Baghdad
It is suggested that the hyper metabolic
status of these patients compromise nutrition and
this decrease insulin-like growth factor-I (IGF-I)
synthesis with subsequent slowing of linear
growth and weight gain (7).
Dental enamel defects are a frequent finding
in primary and permanent dentition. These
defects are generally classified as enamel
hypoplasia or enamel hypo mineralization (8).
World health organization classify enamel defect
into demarcated opacity, diffused opacity and
hypoplasia (1).
Enamel hypoplasia is deficiencies in the
amount or thickness of enamel. These are
quantitative defects as opposed to enamel
opacities, which are qualitative defects.
Opacities involve changes in color and opacity
of enamel, indicating differences in hardness or
quality of enamel (9). Because enamel does not
remodel once it is formed, enamel hypoplasias
are permanent markers left on the tooth crown
that are not lost except from heavy wear or
pathological conditions such as caries (8).
Dental enamel defects have been associated
with a broad spectrum of etiologies, including
systemic stress as malnutrition, resulting in an
insufficient supply of indispensable components
(mineral salts, proteins and vitamins), and

Orthodontics, Pedodontics and Preventive Dentistry124

J Bagh College Dentistry
genetic, local and environmental factors (11). The
cause of the damage does not appear to be of a
major importance because these different local
and systemic stimuli can result in defects that
have similar clinical appearance. The final
enamel represents a record of all significant
insults received during tooth development. (9,
10)
. Some authors have stated that systemic
conditions, such as prenatal or perinatal illness,
low birth weight, regular antibiotic consumption,
celiac disease and respiratory disorders, are
associated with dental enamel defects (12, 13).
Among patients with congenital heart
diseases there are limited of studies concerning
the enamel defects in comparison to control
healthy populations, as these studies reported
that the patients with congenital heart defects
have increased prevalence of developmental
enamel defects in comparison to control groups
(14, 15, 16, 17),,
In contrast to the above, other study
found a significantly higher number of
developmental enamel defects in the control
group as compared to the cardiac group (18).
MATERIALS AND MATHODS
The examination involved 60 patients, their
ages range from 5-8 years old recorded
according to the last birthday (1). The patients
were diagnosed as having ventricular septal
defect according to their medical personal files
which presents in Ibn EL-Bitar hospital,
attending the hospital for their diagnosis and
follow up. 30 of those patients were under the
treatment of (diuretics, digoxine and
angiotensine converting enzyme inhibitors) and
30 were without any medications. So, those 60
patients were subdivided into two groups (with
medication VSD and without medication VSD
groups).
A control sample of 30 children was
examined consisted of students in Kindergartens
and primary schools distributed in Baghdad city.
The students were selected randomly depending
on lists of students in each class. Those children
were healthy looking without any general health
problems.
Nutritional status is assessed by using
anthropometric measurements included
measurement of weight and height according to
Trowbidge using Bathroom scale and height
measuring tape. Body Mass Index (BMI) is a
simple index of weight for height; it is defined
as the individual's body weight divided by the
square of his or her height (19).
BMI is used defiantly for children. The BMI
percentile allows comparison with children of
the same gender and age. Children with BMI
Orthodontics, Pedodontics and Preventive Dentistry125
Vol. 23(3), 2011 Enamel defects in relation
that is less than the 5th percentile were
considered malnourished while children with
BMI that is between the 5th and 85th percentiles
were considered well nourished (2).
The modified developmental defects of
enamel index (DDE) were used (1). Enamel
abnormalities were classified into one of three
types on the basis of their appearance. They vary
in their extent, position on teeth surfaces and
distribution within the dentition. Ten index teeth
were examined on the buccal surface only, if any
index tooth is missing, the area was excluded.
These teeth are for permanent: upper left
and right central and lateral incisors, canine, first
premolar and the lower left and right first molar
while for primary teeth: upper left and right
central and lateral incisors, canine, first molar,
and lower left and right second molar.
RESULTS
The distribution of the total sample by
gender is seen in Table 1. Figure 1 illustrates
that a higher percentages of children with
enamel defects were recorded among both
ventricular septal defect groups as compared to
control group. Enamel defect by types for the
primary teeth among ventricular septal defect
and control groups by gender are shown in Table
2. This table illustrates that for the total sample,
the highly significant differences between the
three groups concerning demarcated opacity and
hypoplasia (P <0.01). The least significant
differences test when applied on the total sample
revealed that the highly significant differences
were found between with medication ventricular
septal defect and control groups concerning
demarcated opacity, as well as between both
ventricular septal defect groups and between
with medication ventricular septal defect and
control groups concerning hypoplasia (m.d.=
1.40, 1.30 and 2.00 respectively, P <0.01), the
significant differences were found between with
and without medication ventricular septal defect
groups concerning demarcated opacity
(m.d.=0.80, P <0.05). As well as between
without medication ventricular septal defect and
control groups concerning demarcated and
diffused opacity (m.d.= 0.60, 0.30 respectively,
P <0.05).
For the permanent teeth, Table 3 illustrates
that the mean value of demarcated opacity
among the total sample is higher than diffused
opacity and hypoplasia. However, no significant
differences among the three groups for
demarcated opacity, diffused opacity and
hypoplasia (P >0.05).
J Bagh College Dentistry Vol. 23(3), 2011
Concerning nutritional status, Table 4
illustrates the distribution of children among
with and without medication ventricular septal
defect groups according to nutritional status by
gender. For the total sample, the percentage of
children with malnourishment was higher than
well nourished among both with and without
medication ventricular septal defect groups
(60% and 40%, respectively), this was true for
total gender. All children involved in the control
group were well nourished children. Enamel
defects by types for primary and permanent teeth
according to nutritional status among with and
without medication ventricular septal defect
groups are shown in Table 5. For the primary
teeth, the significant difference between with
and without medication ventricular septal defect
groups was found concerning the hypoplasia
within malnourished children (t=2.28, df= 34, P
<0.05). The enamel hypoplasia for primary and
permanent teeth showed higher mean value
among malnourished children compared to well
nourish among both ventricular septal defect
groups with statically no significant difference.
DISCUSSIONS
Data of the present study revealed that 60%
of children among both ventricular septal defect
groups were in malnourished status. This may be
related to their medical condition as the size of
the left to right shunt and the abnormal
hemodynamic circulation are important factors
in the etiology of impaired growth among
children with ventricular septal defect (6). This
might strengthen the fact that congestive heart
failure among this group of children increase the
severity of the nutritional impairment (7, 20).
Those children may suffer from loss of appetite,
due to the side effect of medications, digoxin
toxicity or azotemia secondary to angiotensin
converting enzyme inhibitors or overzealous
diuretic use can both cause anorexia (21). This
Table 1: The distribution of total sample by gender
Without medication With medication
Control group
VSD group
% No. % No.
60.0 18 60.0 18
40.0 12 40.0 12
100 30 100 30
Orthodontics, Pedodontics and Preventive Dentistry126
Enamel defects in relation
may increase the malnourishment for those
children.
The results of the study revealed that enamel
defects in both primary and permanent dentition
were higher in ventricular septal defect groups
compared to control group with statistically
highly significant differences between the three
groups regarding the primary dentition. This
observation was also recorded by previous
studies conducting among children with
congenital heart disease (14, 15, 16, 17). This could
be attributed to the metabolic defect as
malnutrition during growth and development of
the teeth.
The primary teeth showed higher mean
values of these defects compared to permanent
dentition and this related to the time of
development and calcification of the primary
teeth as well as time of defect such as
malnutrition that affected these teeth (22).
According to many references, the period of
susceptibility to nutritional deficiencies begins
with the development of the deciduous teeth at
about four months in uterus and lasts until the
crowns of permanent teeth are completed at
about the six years of life (10, 12).
The demarcated opacity for both dentitions
was recorded to be the most prevalent type
among the control group; this result is in
accordance with many authors (23-26). While
among ventricular septal defect groups, enamel
hypoplasia was noticed with higher mean value
among the primary teeth followed by
demarcated opacity.
The hypoplastic defects for both primary
and permanent teeth were found to be higher
among malnourished children compared to well
nourished regarding both ventricular septal
defect groups as the deficiency of nutritional
elements can affect epithelial cell function and
the mineralization process, such a situation may
produce a developmental setting conducive to
formation of the hypoplastic defect (27).
Age groups
VSD group Gender
(year)
% No.
60.0 18 Male
40.0 12 Female Total
100 30 Total
J Bagh College Dentistry Vol. 23(3), 2011 Enamel defects in relation

Figure 1: Distribution of children with enamel defects among with medication VSD, without
medication VSD and control groups by gender

Table 2: Enamel defect by types (mean and standard deviation) of the primary teeth among
with medication VSD, without medication VSD and control groups gender
Control Without medication With medication

(year)
F- Enamel defect

Age
group VSD group VSD group Gender
value by types
±SD mean ±SD mean ±SD mean
6.38** 0.24 0.06 0.79 0.50 1.60 1.28 Demarcated opacities
0.93 0.00 0.00 0.96 0.28 0.47 0.11 Diffused opacities Male
5.58** 1.18 0.28 1.54 0.83 2.68 2.33 Hypoplasia
3.91* 0.00 0.00 1.40 0.83 2.10 1.67 Demarcated opacities

Total
0.89 0.00 0.00 0.89 0.33 0.58 0.17 Diffused opacities Female
3.57* 0.00 0.00 1.98 0.92 2.31 1.92 Hypoplasia
10.12** 0.18 0.33 1.07 0.63 1.79 1.43 Demarcated opacities
1.86 0.00 0.00 0.92 0.30 0.51 0.13 Diffused opacities Total
9.28** 0.91 0.17 1.70 0.87 2.51 2.17 Hypoplasia
* Significant P < 0.05, ** Highly significant P < 0.01

Table 3: Enamel defect by types (mean and standard deviation) of the permanent teeth among
with medication VSD, without medication VSD and control groups by gender
Control Without medication VSD With medication VSD
F- Enamel defect
Age

group group group Gender

value by types
±SD mean ±SD mean ±SD mean
Demarcated
0.57 2.35 0.61 1.84 1.28 1.42 0.83
opacities
Male
0.80 0.00 0.00 0.47 0.11 0.51 0.17 Diffused opacities
1.04 0.00 0.00 0.65 0.22 0.47 0.11 Hypoplasia
Demarcated
1.59 0.58 0.17 0.78 0.33 1.34 0.83
Total

opacities
Female
------ 0.00 0.00 0.00 0.00 0.00 0.00 Diffused opacities
------ 0.00 0.00 0.00 0.00 0.00 0.00 Hypoplasia
Demarcated
0.74 1.85 0.43 1.56 0.90 1.37 0.83
opacities
Total
0.79 0.00 0.00 0.37 0.07 0.40 0.10 Diffused opacities
1.02 0.00 0.00 0.51 0.13 0.37 0.07 Hypoplasia

Table 4: The distribution of children among with and without medication VSD groups
according to nutritional status by gender

Orthodontics, Pedodontics and Preventive Dentistry127

 J Bagh College Dentistry Vol. 23(3), 2011 Enamel defects in relation

With medication VSD group Without medication VSD group

Well nourished Malnourished Well nourished Malnourished
Age group (Years)
Gender Total no. No. % No. % No. % No. %
M 18 8 44.5 10 55.5 6 33.4 12 66.6
F 12 4 33.4 8 66.6 6 50.0 6 50.0
Total
T 30 12 40.0 18 60.0 12 40.0 18 60.0

Table 5: Enamel defects by type (mean and standard deviation) of primary and permanent
teeth according to nutritional status among with medication and without medication VSD
groups
Perman Primar Perman Primar statu
Dent

With medication VSD group Without medication VSD group

ition

ition

Enamel defect by types t-value df

Malnourished Well nourished al

Mean ±SD Mean ±SD

Demarcated opacities 1.67 2.06 0.75 0.87 1.42 22
Diffused opacities 0.33 0.78 0.08 0.29 1.04 22
y

Hypoplasia 1.67 2.64 0.83 1.70 0.92 22

Demarcated opacities 0.75 1.54 0.83 1.64 -0.13 22
ent

Diffused opacities 0.08 0.29 0.17 0.58 -0.45 22

Hypoplasia 0.00 0.00 0.00 0.00 ----- ----
Demarcated opacities 1.28 1.64 0.56 1.20 1.51 34
Diffused opacities 0.00 0.00 0.44 1.15 -1.64 34
y

Hypoplasia 2.50 2.43 0.89 1.75 2.28* 34

Demarcated opacities 0.89 1.28 0.94 1.56 -0.12 34
ent

Diffused opacities 0.11 0.47 0.00 0.00 1.00 34

Hypoplasia 0.11 0.47 0.22 0.65 -0.59 34

REFERENCES
1. WHO. Oral health surveys basic methods 4th ed.
World Health Organization. Geneva, Switzerland,
1997.
2. CDC Growth Chart. United States. National center
for health Statistics in collaboration with the
National Center for chronic Disease Prevention and
Health Promotion, 2000.
3. Webb G, Smallhorn J, Therrien J, Redington A.
Disease of the heart, Pericardium, and Pulmonary
Vascular Bed: Braunwald's heart disease. 8th ed.
Saunders Elsevie , 2008.
4. Crawford M, Dimarco J, Paulas W. Cardiology. 2nd
ed. St Louis, Philadelphia, 2004.
5. Lippy P, Bonow R, Mann D, Zipes D, Braunwald
E. Braunwald's heart disease: A textbook of
cardiovascular medicin. 8th ed. Saunders Elsevier.
Philadelphia, 2008.
6. Goldner M, Martins M, Mendes A. Craniofacial
characteristics of patients with heart disease. Am J
Orthod Detofacial Orthop 2009;136(4):554-8.
7. Soliman A, Madkour A, Abd Galil M, El Zalabany
M, Aziz S, Ansari B. Growth parameters and
endocrine function in relation to echocardiographic
parameters in children with ventricular septal defect
without heart failure. J Tropical Pediatrics 2001;
47(3):146-52.
8. Hoffmann R, De Sousa M, Cyprinano S. Prevalence
of enamel defects and the relationship to dental
caries in deciduous and permanent dentition in
Indaiatuba, Sao Paulo, Brazil. Cad Saude Publica
2007; 23(2):435-44.
9. Frazão P, Peverari A, Forni T, Mota A, Costa L.
Dental fluorosis: comparison of two prevalence
studies. Cad Saude Publica 2004; 20(4):1050-8.
10. Dini E, Holt R, Bedi R. Prevalence of caries and
developmental defects of enamel in 9-10 year old
children living in areas in Brazile with differing
water fluoride histories. Br Dent J 2000; 188(3);
146-9.
11. Rug-Gunn A, Nunn J. Nutrition and tooth
development: Rug-Gunn A. Nunn J. Nutririon, diet
and oral health textbook. Oxford University Press.
1999:79-93.
12. Jälevik B, Norėn J, Klingberg G, Barregård L.
Etiologic factors influencing the prevalence of
demarcated opacities in permanent first molars in a
group of Swedish children. Eur J Oral Sci 2001;
109(4):230-4.
13. Wierink C, Van Diiermen D, Aartman I, Heymans
H. Dental enamel defects in children with celiac
disease. Int J Paediatr Dent 2007;17(3):163-8.
14. Radford D, Throng H, Beard L, Ferrante A.
Immunoglobin IgG subclass dificiencies in children
with congenital heart disease. Pediatr Allergy
Immunol 1991; 1:41-5.
15. Hallett K, Radford D, Seow W. Oral health of
children with congenital cardiac diseases: A
controlled study. Ped Dent 1992; 14(4):224-30.
16. Zafar S, Yasin S, Siddiqi A, Naz F. Oral health
status of paediatric cardiac patients: A case –control
study. International Dentistry Sa 2008;10:6.
17. Tasioula V, Balmer R, Parsons J. Dental health and
treatment in a group of children with congenital
heart disease. Pediator Dent 2008; 30(4):323-8.
18. Franco E, Saunders C, Roberts G, Suwanprasit A.
Dental disease, caries related microflora and
salivary IgA of children with sever congenital
cardiac disease: an epidemiological and oral
microbial survey. Pediatric Dentistry 1996;
18(3):228-35.
19. Trowbridge F. Evaluating nutritional status of
infant and children. In: Paige D. eds. Clinical

Orthodontics, Pedodontics and Preventive Dentistry128

J Bagh College Dentistry Vol. 23(3), 2011
nutrition. 2nd ed. The CV Mosby Comp. St Louis
Washington D.C.Toronto. 1988; 119-36.
20. El-Mahdi L, Hashim M, Ali S. Parental knowledge
of their children's congenital heart disease and its
impact on their growth. Khartoum Med J 2009;
2(2):191-6.
21. Devi S, Jani R. Review on nutritional management
of cardiac disorders in Canines. Veterinary World
2009; 2(12):482-485.
22. Tomczyk J. Soltysiak A. Tomczyk-Gruca M.
Temporal changes in frequency of enamel
hypoplasia in the middle Euphrates valley (Syria).
Human Biol Budapest. 2007; 30:87-97.
23. Al-Nori A. and Al-Talabani N. Developmental
anomalies of teeth and oral soft tissue among 14-15
years old school children in Baghdad city with
special reference to enamel defects. Jordan Dent J.
1993; 8:5-14.
Orthodontics, Pedodontics and Preventive Dentistry129
Enamel defects in relation
24. Al-Dahan Z. Enamel opacities prevalence and some
associated etiological factors in Iraqi children in
Baghdad city. Iraqi Dent J. 1998; 23:35-53.
25. Gatta E. Primary teeth emergence and enamel
anomalies in relation to nutritional status among 4-
48 months old children in Baghdad city, Iraq.
Master thesis submitted to the college of Dentistry,
University of Baghdad. 2005.
26. Droosh M. Protein-energy malnutrition in relation
to oral health condition among 6 and 9 year old
primary school children in Sulaimania city in Iraq.
M. Sc. Thesis, College of Dentistry, University of
Baghdad. 2007.
27. Luckas J. Walimbe S. Floyed B. Epidemiology,
enamel hypoplasia in deciduous teeth: Explaining
variation in prevalence in Western India. Am J
Human Biol. 2001; 13:788-807.
J Bagh College Dentistry Vol. 23(3), 2011 Alveolar base and dental arch

Alveolar base and dental arch widths with segmental arch

measurements in different classes of malocclusions
(A comparative study)
Noor F.K. Al-Khawaja B.D.S., M.Sc.(1)
Ausama A. Al- Mulla B.D.S., Dr.D.Sc.(2)

ABSTRACT
Background: The size and shape of the arches have considerable implications in orthodontic diagnosis and
treatment planning. The aim was to evaluate and compare alveolar bases, dental arches and segmental arch
dimensions of class II division 1, class III malocclusion groups with normal occlusion subjects and to check gender
differences and maxillary and mandibular arch widths difference.
Materials and Methods: Dental casts of 62 subjects aged between 18 - 28 years were included in the study. They
were equally divided between males & females, consisting of 26 class I normal, 22 Class II division 1, and 14 Class III
malocclusion and eleven liner measurements were utilized for each dental arch.
Results: All measured dimensions were greater in males than in females except for mandibular inter alveolar premolar
width and maxillary left canine molar distance in class III malocclusion and in maxilla than in mandible except inter
molar width in class II and class III groups and alveolar base dimensions in class III malocclusion. In class I all
measurements were wider than class II division 1 while, in class III was wider than class I in all mandibular alveolar
base and mandibular inter premolar width and wider in all maxillary dental arch widths, all mandibular alveolar base
dimensions and mandibular inter canine and premolar widths than class II division 1 group.
Conclusion: Maxillary molar teeth in subjects with Class II division1 tend to incline buccally to compensate the
insufficient alveolar base, while subjects with Class III malocclusion maxillary posterior teeth tend to incline lingually
and mandibular posterior teeth inclined buccally due to the restriction in maxillary arch.
Key words: Alveolar base; dental arch; class I normal; class II division 1 and III. (J Bagh Coll Dentistry 2011;23(3): 130-
136).

Class II malocclusion is reported as the most

INTRODUCTION
A survey of arch size could help the clinician
in choosing correctly shaped stock impression
trays for prosthodontic treatment. In addition to
the selection of stock trays, the sizes of artificial
teeth and the overall form of the artificial dental
arch at the wax trial stage are amenable to
modification by the dental surgeon in orthodontic
treatment.(¹)
The size and shape of the arches have
considerable implications in orthodontic
diagnosis and treatment planning, affecting the
space available, dental esthetics, and stability of
the dentition. (²)
Investigators have studied the growth of arch
widths in persons with normal occlusion, and
compared these values with those of different
malocclusion samples. (3-8) however; there is
considerable controversy among the results
presented in the literature.
Information regarding maxillary arch
dimensions in human populations is important to
clinicians in orthodontics, prosthodontics, and
oral surgery. It is also of interest to
anthropologists and other students of human oral
biology. (9)
(1) MSc. Student, Department of Orthodontics, College of
Dentistry, Baghdad University
(2) Professor, Department of Orthodontics, College of Dentistry,
Baghdad University
frequently seen skeletal disharmony in
orthodontic population. (10-15)
Transverse component in Class II patients is
of great importance as sagittal or vertical
components. Some of the authors evaluating
transverse dimensions had reported that
maxillary arch was narrower in patients with
Class II, division 1 malocclusion, and an
expansion was needed during or before
treatment. (16-20) besides, Varella (21) had reported
that the deficient transversal growth of the
maxilla and the sagittal growth of the mandible
appeared to cause the typical Class II occlusion.
However, in one of the earlier studies, Fröhlich
(4)
found no difference in transverse dimension
between Class I and Class II subjects.
Investigators have recommended strongly the
early detection of all Classes of malocclusion (22)
Furthermore; they endorse preventive and
interceptive orthodontics and dentofacial
orthopedics for young patients to avoid, or at
least to minimize the occurrence of Class III
malocclusion at the adult stage.
The prevalence of Class III malocclusion is
reported to be 16.8% by Garner and Butt(23) in
the Kenyan, 14% by Salzmann(24) in the
American, and 1.4% by Solow and Helm(25) in
the Danish populations. Among 965 Turkish
children, in the region of Konya, Turkey, a 3.5%

Orthodontics, Pedodontics and Preventive Dentistry130

J Bagh College Dentistry Vol. 23(3), 2011 Alveolar base and dental arch

incidence of Class III malocclusion was and females. Accordingly, the sample was
found.(26) distributed into 6 unequal groups (Table1).
Certain selected tooth - related points, visible
in an occlusal and buccal, view were carefully
MATERIALS AND METHODS marked bilaterally with a sharp pencil (0.5 pencil
Out of randomly selected subjects 320 Iraqi marker) in the maxillary and mandibular study
adults (156 males and 164 females) aged casts to identify the landmarks that will be used
between 18 and 28 years were examined from the for measuring the planned dental arch
students and patients of College of Dentistry, dimensions for this study (figure 1 and 2).
Baghdad University. Only 64 subjects met the One hundred and twenty four upper and
criteria of the samples, two of them were lower dental casts were marked and analyzed.
excluded due to defects in the cast. Twenty two measurements were taken for each
Sample criteria subject. The dental arch dimension
1. All the subjects were Iraqi Arab in origin. measurements were carried out using a digital
2. Having complete permanent dentition vernier “Serial No.: 7156682; sensitivity: 0.01;
regardless the third molars. Mitutoyo Digimatic, Japan. (Table 2).
3. The age ranged between 18-28 years.
4. No attrition, no abrasion in all teeth
5. Healthy gingival tissue with no gingivitis or
periodontitis or any gum recession.
6. Mild (1-2mm) or no crowding or spacing in all
dental classes.
7. No rotation and normal canine inclination.
8. Intact tooth structure, no fracture, caries,
trauma or heavy restoration.
9. No history of significant medical disease or
trauma.
10. No previous orthodontic, prosthetic or
surgical treatment was recorded.
The sample was categorized by the subjects`
angle classification and then by gender, the Figure 1: Maxillary cast measurements
subjects` angle classification was done according
to Uysal et al. (27-28) into three dental classes:
1. Class I normal occlusion, Class I canine and
molar relationship with well-aligned upper and
lower dental arches and over jet ranged
between 1-4 mm and no cross bite even in
single tooth.
2. Class II malocclusion, Bilateral Class II molar
relationship in centric occlusion with the
distobuccal cusp tip of the maxillary first
molar within one mm (anterior or posterior)
from the buccal groove of the mandibular first
molar, bilateral canine class II and protrusive
maxillary incisors and overjet ranged 4 - 10
mm and no cross bite even in single tooth Figure 2: Mandibular arch measurements
exclusion of class II division 2 and class II
subdivision. Training and standardization procedures are
3. Class III malocclusion, Bilateral Class III essential in any research work.(29) So prior to
molar relationship in centric occlusion with starting the measurement procedures for the main
the cusp tip of the maxillary second premolar study, a pilot study was performed on 10 sets (10
within the range of one mm (anterior or upper and 10 lower casts) of randomly selected
posterior) from the buccal groove of the sets to assess the reliability and accuracy of the
mandibular first molar, bilateral canine class measurements using Paired sample “t-test” was
III with edge to edge or reversed over jet and applied to test significance differences showed
no posterior cross bite. no significant differences between two
Then each group was subdivided into two even measurements in inter and intra examiner
subgroups according to their gender, males calibrations.

Orthodontics, Pedodontics and Preventive Dentistry131

J Bagh College Dentistry Vol. 23(3), 2011
RESULTS
Descriptive statistics (mean, standard
deviation, minimum, maximum and range) and
statistical comparisons of dental and alveolar
width measurements for dental casts in three
groups (normal occlusion, class II division 1 and
Class III malocclusion) are obtained. According
to independent samples t-test to differentiate
between genders, In class I normal occlusion the
mean values for all measurements were higher
for males than that for females with significant
differences at P<0.001 in all alveolar base
dimensions, UC-C, UP-P, LM-M, ULIC and
LRIC and at P<0.01 in UM-M, LC-C, LP-P,
URIC and LDAP and P<0.05 in UDAP, LLIC
and LRCM while in class II division 1 also all
values were higher in males than in females with
significant differences at P<0.001 in only UAC-
C and P<0.01 inter canine widths, UAP-P, UAM-
M, left IC distance and UDAP and P<0.05 in
LAP-P and right IC distances. Finally in class III
malocclusion all measurements had a higher
mean values in males than in females except
LAP-P and ULCM distance and no significant at
P>0.05 in all except in UC-C and LP-P at P<0.01
and LM-M at P<0.05
One way analysis of variance (ANOVA) and
least significant difference (LSD) test to compare
between three groups as in table 3, showed a very
highly significant difference in mandibular inter
alveolar canine and premolar widths and a highly
significant difference in mandibular inter
alveolar molar width and no significant
difference in the rest of measurements among
females in class I normal occlusion, class II and
class III malocclusion groups, these results were
specified by least significant difference (LSD)
test as follow (Table 4):
1. Mandibular inter alveolar canine width:
LSD test showed a highly significant difference
between class I normal occlusion group and class
II group on one hand and class III malocclusion
group on the other, while between class II &
class III malocclusion groups it showed a very
highly significant difference.
2. Mandibular inter alveolar premolars
width: LSD test showed a highly significant
difference between class I normal occlusion
group and both class II and class III
malocclusion groups, and a very highly
significant difference between class II & class III
malocclusion groups.
3. Mandibular inter alveolar molars width:
LSD test showed no significant differences
except between class II and class III
malocclusion groups where it showed a highly
significant difference.
Orthodontics, Pedodontics and Preventive Dentistry132
Alveolar base and dental arch
One way Analysis of variance (ANOVA)
showed a very highly significant difference in
mandibular inter alveolar canine width and a
highly significant difference in mandibular inter
alveolar molar width and a significant difference
in maxillary inter alveolar canine and mandibular
inter alveolar premolar widths among males in
class I normal occlusion, class II and class III
malocclusion group, these results were specified
by least significant difference (LSD) test as in
(Table 5):
1. Maxillary inter alveolar canine width: LSD
test showed a significant difference between
class I normal occlusion and class III
malocclusion groups.
2. Mandibular inter alveolar canine width : LSD
test showed a very highly significant
difference between class II and class III
malocclusion groups, and a highly significant
difference between class I normal occlusion
and class II malocclusion groups.
3. Mandibular inter alveolar premolar width:
LSD test showed a highly significant
difference between class I normal occlusion
and class II malocclusion groups and a
significant difference between class II and
class III malocclusion groups.
4. Mandibular inter alveolar molar width: LSD
test showed a highly significant difference
between class I normal occlusion and class II
malocclusion groups and a significant
difference between class II and class III
malocclusion groups.
DISCUSSION
In general, it is obvious that the mean values
of all the measured variables (dental arch width,
alveolar width and perimeter) confirmed the
accepted view that the maxillary dental arch is
larger in all dimensions than the mandibular
dental arch as the maxillary dental arch overlaps
the mandibular dental arch, (30-34) except in class
III where it was found that alveolar widths are
larger in mandible than in maxilla this may be
attributed to prognathic mandible in class III
cases.
This study has confirmed the view that
male’s dental arches are larger than that of
female’s ones since all of the mean values are
larger in male subjects than that of the females
and this agrees with Brodie (35); Younes (9) and Al
– Hadithy (36) and this may be attributed:
• The smaller and smoother bony ridge
and alveolar process in females.
• The average weakness of musculature in
females that play an important role in facial
J Bagh College Dentistry Vol. 23(3), 2011
breadth measurements, width and height of the
dental arch.
In genders differences some of variables
showed significant differences and other no.
these may agree with some studies and may be
disagreed with other which could be due to
ethnic differences or sample size and selection
differences or may be different in point selection.
Class I normal occlusion and Class II division
1 malocclusion
All the measured variables were higher in
both maxillary and mandibular arches for both
males and females in class I normal occlusion
group than in class II malocclusion group except
for the mandibular inter premolar width.
Clinicians have speculated that nasal obstruction,
finger habits, tongue thrusting, low tongue
position, and abnormal swallowing and sucking
behaviors were reasons for narrower maxillary
dental arch widths in Class II division 1
malocclusions compared with a normal occlusion
sample, (28) moreover Staley et al.(37); Sayin and
Turkkahraman(8) showed that the maxillary
dental arch as a whole is narrower in adults with
Class II division 1 malocclusion than it is in
adults with normal occlusion this appeared to be
caused by palatelly tipped teeth and also by
narrower bony bases of the dental arch. Their
results showed that transverse discrepancy in
Class II division 1 patients originated from upper
posterior teeth and not from the maxillary
alveolar base.
The results of this study supported by Uysal
et al. (28) who reported that subjects with Class II
division 1 malocclusion tend to have the
maxillary molar teeth inclined buccally to
compensate for the insufficient alveolar base. For
that reason, rapid maxillary expansion rather than
slow expansion may be considered before or
during the treatment of a Class II division 1
patient.
Disagreement among studies of arch widths
in Class II malocclusions may be explained by
several factors: gender dimorphism, ethnic and
racial differences, sample selection and size, and
age of the subjects.
Class I normal occlusion and Class III
malocclusion
In this study, the mandibular alveolar and
mandibular inter premolar measurements
associated with Class III occlusion were wider
than the normal occlusion sample. A possible
explanation for the increased arch width
associated with Class III occlusion is that the
sum of all the mesiodistal widths of the dental
Orthodontics, Pedodontics and Preventive Dentistry133
Alveolar base and dental arch
units around an arch represents a specific
dimension and this supported by Sperry et al. (38)
showed that the Class III group with mandibular
prognathism more commonly had mandibular
tooth size excess for the overall ratio than the
Class I and Class II groups. Similarly, Lavelle (39)
and Nie and Lin (40) showed that Class III cases
are characterized by smaller maxillary tooth
dimensions and bigger lower teeth. Hnat et al. (41)
also reported that, when the mandibular tooth
size is increased, mandibular arch length and
arch width increase occurs, and this suggestion
supports our results. The findings of this study
indicated that all the maxillary dental and
alveolar width measurements were narrower in
subjects with Class III malocclusion when
compared with the normal occlusion sample.
Lingually positioned maxillary posterior
cross bites are often seen in the Class III
malocclusion. One could speculate that during
eruption in Class III subjects, the maxillary
posterior teeth compensate for the buccal
relationships (that result from the anteroposterior
displacement of the jaws) by palatal movement
to avoid inappropriate contacts with the lower
teeth. Besides, it was widely believed that a wide
and big mandible obstructed growth and
development of the maxillary dental and alveolar
arches and agree with Braun et al. (1) found that
the mandibular dental arch widths associated
with Class III occlusions are, on an average, 2.1
mm wider than the Class I mandibular arches
beginning in the premolar area and the finding of
Uysal et al. (27) showed subjects with Class III
malocclusion tend to have the maxillary posterior
teeth inclined to the lingual direction and
mandibular posterior teeth inclined to the buccal
direction because of the restriction of maxillary
growth and development. Therefore, rapid
maxillary expansion may be considered before or
during the treatment of a Class III patient.
REFERENCES
1. Braun S, Hnat WP, Freder DE, Legan HL. The form
of human dental arch. Angle Orthod 1998; 1:29-36.
2. Lee RT. Arch width and form: a review. Am J Orthod
Dentofacial Orthop 1999; 115:305–13.
3. Solow B. The pattern of craniofacial associations.
Acta Odontol Scand 1966; 24:46.
4. Fröhlich FJ. A longitudinal study of untreated Class II
type malocclusion. Trans Eur Orthod Soc 1961;
37:137–59.
5. Slagsvold O. Associations in width dimensions of the
upper and lower jaws. Trans Eur Orthod Soc 1971;
43:465–71.
6. Enlow DH, Hans MG. Essentials of Facial Growth.
Philadelphia, Pa: WB Saunders 1996:1–280.
J Bagh College Dentistry Vol. 23(3), 2011
7. Walkow TM, Peck S. Dental arch width in Class II
division 2 deep-bite malocclusion. Am J Orthod
Dentofacial Orthop 2002; 122:608–13.
8. Sayin MO, Turkkahraman H. Comparison of dental
arch and alveolar widths of patients with Class II
division 1 malocclusion and subjects with Class I ideal
occlusion. Angle Orthod 2004; 74:356–60.
9. Younes SA. Maxillary arch dimensions in Saudi and
Egypt population sample. Am J Orthod Dentofacial
Orthop 1984; 85:83–8.
10. Ast DB, Carlos JP, Cons DC. Prevalence and
characteristics of malocclusion among senior high
school students in up-state New York. Am J Orthod
1965; 51: 437–45.
11. Moyers RE. Handbook of orthodontics. Year
Book Medical Publisher 1988; PP. 123,126.
12. Burgersdijk R, Truin GJ, Frankenmolen F,
Kalsbeek H, van’t Hof M, Mulder J. Malocclusion and
orthodontic treatment need of 15- 74-year-old Dutch
adults. Commun Dent Oral Epidemiol 1991;19:64–7.
13. Tang EL. The prevalence of malocclusion
amongst Hong Kong male dental students. Br J Orthod
1994; 21:57–63.
14. Willems G, De Bruyne I, Verdonck A, Fieuws
S, Carels C. Prevalence of dentofacial characteristics
in a Belgian orthodontic population. Clin Oral
Investig. 2001; 5:220–6.
15. Silva RG, Kang DS. Prevalence of
malocclusion among Latino adolescents. Am J Orthod
Dentofacial Orthop. 2001; 119:313–5.
16. Bishara SE, Bayati P, Jakobsen JR.
Longitudinal comparisons of dental arch changes in
normal and untreated Class II division 1 subjects and
their clinical implications. Am J Orthod Dentofacial
Orthop 1996; 110:483–9.
17. Tollaro I, Baccetti T, Franchi L, Tanesescu CD.
Role of posterior transverse interarch discrepancy in
Class II, division 1 malocclusion during the mixed
dentition phase. Am J Orthod Dentofacial Orthop
1996; 110:417–22.
18. Baccetti T, Franchi L, McNamara JA Jr,
Tollaro I. Early dentofacial features of Class II
malocclusion: a longitudinal study from the deciduous
through the mixed dentition. Am J Orthod Dentofacial
Orthop 1997; 11:502–9.
19. McNamara JA Jr, Brudon WL, Kokich VG.
Orthodontics and Dentofacial Orthopedics. Ann
Arbor, Mich: Needham Press; 2001: 63–84.
20. McNamara JA Jr. Early intervention in the
transverse dimension: is it worth the effort? Am J
Orthod Dentofacial Orthop 2002; 121:572–4.
21. Varella J. Early developmental traits in Class II
malocclusion. Acta Odontol Scand 1998; 56:375–7.
22. El - Mangoury NH, Mostafa YA.
Epidemiologic panorama of dental occlusion. Angle
Orthod 1990; 60:207–14.
23. Garner LD, Butt MH. Malocclusion in Black
Americans and Nyeri Kenyans. Angle Orthod 1985;
55:139–46.
Orthodontics, Pedodontics and Preventive Dentistry134
Alveolar base and dental arch
24. Salzmann JA. Malocclusion and treatment need
in United States youths 12–17 years of age [editorial].
Am J Orthod1977; 72:579–81.
25. Solow B, Helm S. A method for tabulation and
statistical evaluation of epidemiologic malocclusion
data. Acta Odontol Scand 1968; 26:63–88.
26. Basciftci FA, Demir A, Uysal T, Sari Z.
Prevalence of orthodontic malocclusions in Konya
region school children [in Turkish, abstract in
English]. Turk J Orthod 2002; 15(2):92– 8.
27. Uysal T, Usumez S, Memili B, Sari Z. Dental
and alveolar arch widths in normal occlusion and class
III malocclusion. Angle orthod 2005a; 75:809-13.
28. Uysal T, Usumez S, Memili B, Sari Z. Dental
and alveolar arch widths in normal occlusion, class II
division 1 and class II division 2. Angle orthod 2005b;
75:941-7.
29. Rudge SJ. A computer program for the analysis
of study models Europ. J Orthod 1982; 4:269-73.
30. Cohen J. Growth and development of dental
arches in children. JADA 1940; 27: 1250-60.
31. Moorrees CFA. Growth changes of the dental
arches –A longitudinal study. J Canad Dent Assoc
1958; 24:449-57.
32. Sillman JH. Dimensional changes of dental
arches: Longitudinal study from birth to 25 years .Am
J Orthod Dentofac Orthop 1964; 50:824-42.
33. Knott VB. Longitudinal study of dental arch
widths at four stages of dentition. Angle Orthod 1972;
42:387-94.
34. Eid A, EL-Namrawy M, Kadry W. The
relationship between the width, depth and
circumference of the dental arch for a group of
Egyptian school children. Egyptian Orthodontic J
1987; 1:113-36.
35. Bordie AP. The growth pattern of the human
head from the third month to the eight year of life. Am
J Orthod Dentofacial Orthop 1941; 68:209-62.
36. Al - Hadithy SF. Dental arch dimensions and
forms in Sulaimania Kurdish population sample aged
16-24 years with class I normal occlusion. Master
thesis, Department of Orthodontics, University of
Baghdad, 2005.
37. Staley RN, Stuntz WR, Peterson L. A
comparison of arch widths in adults with normal
occlusion and adults with class II division 1 occlusion.
Am J.Orthod.Dentofac Orthop 1985; 88:163-9.
38. Sperry TP, Worms FW, Isaacson RJ, Speidel
TM. Toothsize discrepancy in mandibular
prognathism. Am J Orthod 1977; 72:183–90.
39. Lavelle CLB. Maxillary and mandibular tooth
size in different racial groups and in different
occlusion categories. Am J Orthod 1972; 6:29–37.
40. Nie Q, Lin J. Comparison of intermaxillary
tooth size discrepancies among different malocclusion
groups. Am J Orthod Dentofacial Orthop 1999;
116:539–44.
41. Hnat WP, Braun S, Chinhara A, Legan HL. The
relationship of arch length to alterations in dental arch
width. Am J Orthod Dentofacial Orthop 2000;
118:184–8.
J Bagh College Dentistry Vol. 23(3), 2011 Alveolar base and dental arch

Table 1: Sample size and mean age and over jet for each group
Samples N Males Females Age Over jet
Class I 26 13 13 22.57±2.39 2.09±0.84
Class II i 22 11 11 21±2.51 5.55±2.17
Class III 14 7 7 20.79±1.53 -2.03±1.66

Table 2: Maxillary and Mandibular Dental and Alveolar Width Measurements Used in the
Study
1 Maxillary intercanine width (UC-C): the distance between the cusp tips of the right and left canines or the
center of the wear facets in cases of attrition.
2. Maxillary interpremolar width (UP-P): the distance between the cusp tips of the right and left first premolars.
3. Maxillary intermolar width (UM-M): the distance between the mesiobuccal cusp tips of the right and left first
molars.
4. Mandibular intercanine width (LC-C): the distance between the cusp tips of the right and left mandibular
canines.
5. Mandibular interpremolar width (LP-P): the distance between the cusp tips of the right and left mandibular
first premolars.
6. Mandibular intermolar width (LM-M): between the most gingival extensions of the buccal grooves on the first
molars or, when the grooves had no distinct terminus on the buccal surface, between points on the grooves
located at the middle of the buccal surfaces.
7. Maxillary canine alveolar width (UAC-C): the distance between two points at the mucogingival junctions
above the cusp tips of the maxillary right and left canines.
8. Maxillary premolar alveolar width (UAP-P): the distance between two points at the mucogingival junctions
above the interdental contact point of the maxillary first and second premolars.
9. Maxillary molar alveolar width (UAM-M): the distance between two points at the mucogingival junctions
above the mesiobuccal cusp tips of the maxillary first molars
10. Mandibular canine alveolar width (LAC-C): the projection of UAC-C point in the lower jaw
11. Mandibular premolar alveolar width (LAP-P): the projection of UAP-P point in the lower jaw
12. Mandibular molar alveolar width (LAM-M): the projection of UAM-M point in the lower jaw.
13. Maxillary and mandibular incisor canine distance (IC): distance from midway between two central incisors
to canine cusp tip for right and left to represent anterior arch segment length
14. Maxillary and mandibular canine molar distance (CM): distance from canine cusp tip to misobuccal cusp tip
of 1st molar for right and left representing buccal segment length.
15. Maxillary and mandibular dental arch perimeter (DAP): sum of anterior and buccal segmental length.

Orthodontics, Pedodontics and Preventive Dentistry135

J Bagh College Dentistry Vol. 23(3), 2011 Alveolar base and dental arch

Table 3: Differences among dental classes Table 4: Least significant difference (LSD)
for all the measured variables by ANOVA test of females in different classes
test according to gender

Table 5: Least significant difference (LSD)

test of males in different classes

Orthodontics, Pedodontics and Preventive Dentistry136

J Bagh College Dentistry Vol. 23(3), 2011 The morphology and texture

The morphology and texture of Iraqi skeletal class II

young adults (Cephalometric study)
Raoof R. Toma, B.D.S, MSc. (1)
Nagham Al-Mothaffar B.D.S., MSc. (2)

ABSTRACT
Background: Different studies concerning craniofacial morphology of skeletal Class II have reported a lot of
controversies in their results. The aim of the present study is to study the types of class II that can be found what are
the texture and craniofacial growth pattern in each type rather than in the loose context of "Class II".
Materials and methods: The skeletal class II sample included 104 pretreatment digital lateral cephalometric
radiographs (18-30 years) who were selected on the basis of Beta angle [<27°] and divided into five groups
according to the location of maxilla and mandible in relation to the anterior cranial base (SNA and SNB angles).
Another 30 radiographs were selected as a control group (normal SNA and SNB angles, Beta angle 27°-35°). Fourteen
angular and nine linear measurements were digitized and recorded using AutoCAD 2010 computer program.
Results and conclusions: In comparison with skeletal class I, skeletal class II had no significant difference in anterior
and posterior cranial base lengths and facial heights. The individuals with othognathism of upper jaw and
retrognathism of lower had the highest anterior facial height and the least mandibular base length, while those with
prognathism of upper jaw with orthognathism of lower had the highest gonial angle with least articular angle.
Combination of prognathism of maxilla with retognathism of mandible showed vertical growth pattern with most
convex profile. Retrognathism of both upper and lower jaws appeared in individuals with highest saddle and palatal
plane angle with the least gonial angle, while individuals with prognathism of both jaws showed horizontal growth
pattern with highest posterior facial height and least mandibular plane angle and anterior facial height.
Key words: Skeletal class II, class II, cephalometrics. (J Bagh Coll Dentistry 2011;23(3): 137-143).

INTRODUCTION One of the approaches for assessment of

The skeletal relationship is not only
important in the part it plays in occlusal
development; it also plays a major part in
orthodontic treatment. It seems likely that
orthodontic treatment which is confined to tooth
movement has little effect on the size, shape or
relative positions of the basal parts of the jaws.
Its only direct effect is on tooth position and on
alveolar bone position and form. Therefore, as
the teeth must be positioned on the basal bones,
the skeletal relationship must limit the amount of
tooth movement which can be achieved (1). An
analysis of maxillary and mandibular skeletal
positions is essential in planning dentofacial
orthodontic treatment or orthognathic surgery.
The skeletal nature of the patient may have an
effect on the choice of the appliance and the
evaluation of the treatment result (2). The relative
size and anteroposterior position of the maxilla
and the mandible in relation to the rest of the
craniofacial complex has been one of the major
problems dealt by investigators in the fields of
orthodontics and anthropology (3). There are
numerous angular and linear measurements to
assess the sagittal discrepancy between maxilla
and mandible, which is of prime importance in
diagnosis and treatment-planning, all these
measurements have shortcomings (4).
(1) MSc Student, orthodontic department, College of dentistry,
Baghdad University.
(2) Professor, Orthodontic department, College of Dentistry,
Baghdad University.
anteroposterior dysplasia was developed and
named the Beta angle which does not depend on
any cranial landmarks or dental occlusion would
be especially valuable whenever previously
established cephalometric measurements, such as
the ANB angle and the Wits appraisal, cannot be
accurately used because of their dependence on
varying factors (5).
It is important to identify whether the
etiology of skeletal Class II is the maxilla, the
mandible or combination of both of them and as
the treatment should be planned according to the
location of the discrepancies diagnosed in each
individual patient.
MATERIALS AND METHODS
The sample
Out of 679 collected pretreatment digital
true lateral cephalometric radiographs from the
files of the patients who attended different Iraqi
specialist dental centers, class II skeletal
dysplasia were only identified in 104 radiographs
according to Baik and Ververido (5) (Beta angle
less than 27°). The control group consisted from
30 pretreatment digital true lateral cephalometric
radiographs; that had a skeletal class I
relationship (Beta angle 27° - 35°).
The Inclusion Criteria:
1. The samples were adult with an age ranged
between 18-30 years. .
2. All individuals had no apparent oro-facial
deformity, such as cleft palate.

Orthodontics, Pedodontics and Preventive Dentistry137

 J Bagh College Dentistry Vol. 23(3), 2011
3. No apparent jaw fracture or surgical treatment.
4. Accepted quality cephalometric x-rays.
5. Individuals with open bite are excluded.
The methods
Cephalometric analysis
Firstly, to identify the individuals with
skeletal class II (the sample) and those with
skeletal class I (the control group), each lateral
cephalometric radiograph was analyzed by using
AutoCAD program to measure the Beta angle
which should be less than 27° in skeletal class II
and 27°- 35° in skeletal class I.
After importing the picture to the AutoCAD
program, the points were localized, the planes
were determined, and the angles and distances
were measured. The angles were measured
directly as they were not affected by
magnification, while the linear measurements
were divided by scale for each picture to
overcome the magnification.
After measuring the Beta angle, fourteen angular
and eight linear measurements were recorded for
each selected radiograph and all measurements
were put in excel sheet for the statistical
analyses.
Then the sample with class II skeletal dysplasia
was divided into 5 groups according to the
location of the problem; the position of the
maxilla and the mandible in relation to the
anterior cranial base using the SNA and SNB
angles(2); yet, these two angles were normal in
the control group (SNA= 81°-82°; SNB= 78°-
79°)(6) :
Group 1: individuals with normal position of
maxilla and retruded mandible in relation to the
anterior cranial base.
Group 2: individuals with normal position of
mandible and protruded maxilla in relation to the
anterior cranial base.
Group 3: individuals with protruded maxilla and
retruded mandible in relation to the anterior
cranial base.
Group 4: individuals with retruded maxilla and
mandible in relation to the anterior cranial base
Group 5: individuals with protruded maxilla and
mandible in relation to the anterior cranial base.
Cephalometric landmarks, planes, and
measurements
I. Cephalometric Landmarks
1. Point S (Sella): The midpoint of the Sella
turcica (pituitary gland fossa) (7).
2. Point N (Nasion): The most anterior point on
fronto-nasal suture in the median plane (7).
3. Point Ar (Articulare): The point of intersection
of the external dorsal contour of the mandibular
condyle and the temporal bone (8).
Orthodontics, Pedodontics and Preventive Dentistry138
The morphology and texture
4. Point ANS (Anterior Nasal Spine): The tip of
the anterior process of the maxilla and is situated
at the lower margin of the nasal aperture (7).
5. Point PNS (Posterior Nasal Spine): This is a
constructed radiological point, the intersection of
a continuation of the anterior wall of the
pterygopalatine fossa and the floor of the nose. It
marks the dorsal limit of the maxilla (7).
6. Point A (Subspinale): The deepest midline
point on the premaxilla between the Anterior
Nasal Spine and Prosthion (7).
7. Point B (Supramentale): The deepest midline
point on the mandible between Infradentale and
Pogonion (7).
8. Point Pog (Pogonion): It is the most anterior
point on the mandible in the midline (7).
9. Point Me (Menton): The lowest point on the
symphyseal shadow of the mandible seen on a
lateral cephalograms (9).
10. Point Go (Gonion): A point on the curvature
of the angle of the mandible located by bisecting
the angle formed by the lines tangent to the
posterior ramus and inferior border of the
mandible (9).
11. Point Ii (Incisor inferius): The tip of the
crown of the most anterior mandibular central
incisor (7).
12. Point Is (Incisor superius): The tip of the
crown of the most anterior maxillary central
incisor (7).
13. Point Ap 1 (Apicale 1): Root apex of the
most anterior maxillary central incisor (7).
14. Point Ap 1 (Apicale 1): Root apex of the
most anterior mandibular central incisor (7).
15. Point C (The center of the condyle): Found
by tracing the head of the condyle and
approximating its center (5).
II. Cephalometric planes
1. Sella-Nasion plane (S-N).
2. Sella-Articulare plane (S-Ar).
3. Maxillary plane (Max.P).
4. Mandibular plane (MP).
5. Ramus plane (RP).
6. Long axis of the upper incisor (U1).
7. Long axis of the lower incisor (L1).
8. N- A line.
9. N- B line.
10. Denture base limit (AB plane).
III. Cephalometric measurements
A. Angular measurements
1. Beta angle (5):
The Beta angle is a new measurement for
assessing the skeletal discrepancy between the
maxilla and the mandible in the sagittal plane. It
uses 3 skeletal landmarks:
A point (Subspinale), B point (Supramentale), the
center of the condyle (C)
 J Bagh College Dentistry Vol. 23(3), 2011
Next, defining 3 lines:
• Line connecting the center of the condyle C with
B point (C-B line).
• Line connecting A and B points.
• Line from point A perpendicular to the C-B line.
Finally, measuring the Beta angle which is the
angle between the perpendicular line from point
A to CB line and the A-B line. Its values are:
Class I (27°- 35°), Class II < 27° and Class III >
35.
Figure 1: Beta angle
2. SNA angle: the anteroposterior position of
maxilla relative to anterior cranial base (7).
3. SNB angle: It is the anteroposterior position of
mandible relative to the anterior cranial base (7).
4. SN plane-Mandibular Plane Angle (SN-MP):
This angle gives the inclination of the mandible
to the anterior cranial base. It is formed at the
point of intersection of the S-N plane and
mandibular plane. This angle can give an
indication to the type of rotation of the mandible
(10)
. groups and Least significant difference test LSD
5. SN plane-Maxillary Plane Angle (SN-Max.P):
The angle of maxillary plane (ANS-PNS)
inclination in relation to anterior cranial base, it
is formed at the point of intersection of the S-N
plane and maxillary plane(10).
6. Gonial Angle (Ar-Go-Me): The angle between
posterior border of the ramus (Ar-Go) and the
mandibular plane (Go-Me) (7).
7. Articulare angle (S-Ar-Go): This angle formed
at the point of intersection of the S-Ar plane and
the Ar-Go plane (7).
8. Inclination of lower incisor (L1/MP): The
angle between long axis of lower incisor and
mandibular plane (7).
9. Inclination of upper incisor (U1/Max.P): The
angle between the long axis of upper incisor and
maxillary plane (11).
10. Inter-incisal angle (U1-L1): The angle
formed by the intersection of the lines
representing the long axes of the most labial
maxillary and mandibular incisors, posteriorly (3).
Orthodontics, Pedodontics and Preventive Dentistry139
The morphology and texture
11. Basal plane angle (PP-MP): This defines the
angle of inclination of the mandible to the
maxillary base (7).
12. SN- AB plane angle: The angle between the
S-N plane and the AB plane, posteriorly (12).
13. Saddle angle (N-S-Ar): It is the angle
between the anterior and posterior cranial base
(7)
.
14. Sum of the posterior angles: it’s the sum of
saddle (NSAr), articular (S-Ar-Go) and gonial
angle (Ar-Go-Me) (7).
B. Linear Measurements
1. S-N: A distance from Sella to Nasion (7).
2. S-Ar: A distance from Sella to Articulare (7).
3. Maxillary length: the distance from Anterior
Nasal Spine to Posterior Nasal (11).
4. Mandibular length: the distance from Gonion
to Menton (11).
5. Ramus length: The distance between Ar and
Go (7).
6. Upper anterior facial height (UAFH): It’s
measured from N to ANS (13).
7. Lower anterior facial height (LAFH):
measured from ANS to Me (13).
8. Posterior facial height (PFH): measured from
S to Go (13).
Statistical Analyses
1. Descriptive Statistics: Means and Standard
deviations (SD).
2. Inferential Statistics: Paired sample t-test: for
intra-examiner and inter-examiner calibration,
ANOVA test: for the comparison among the
test: for variables that show significant
differences among the study groups in ANOVA
test
RESULTS AND DISCUSSION
The sample in this study was selected at age
between eighteen and twenty nine years old to
minimize the effect of any remaining skeletal
growth (22) as the majority of facial growth is
usually complete by 16-17 years of age (23).
According to the collected sample with skeletal
class II relationship, different relations were
found between the maxilla and mandible in their
relation to the anterior cranial base. The result of
this study showed that each group had nearly
similar percentage of the total sample, as the
individual with retrognathic maxilla and
mandible and individuals with combination of
prognathic maxilla and retrognathic mandible
had about 21% followed by individual with
normal maxilla and retrognathic mandible (20%);
on the other hand individuals with prognathic
maxilla and normal mandible and individuals
J Bagh College Dentistry Vol. 23(3), 2011 The morphology and texture

with prognathic maxilla and mandible had almost

the same percentage of about 19%.
The comparison between different groups of
skeletal Class II and skeletal Class I group
showed that there are great differences in the
craniofacial features as manifested in the lateral
cephalometric radiograph. The differences
between the results of the present study and other
studies may be attributed to different sample size,
criteria of sample selection, or ethnic group.
Group one:
Individuals in this group displayed a
significant retrognathic skeletal profile which The upward rotated palatal plane was
was because of retrognathic mandible combined slightly increased, whereas the mandibular length
with a normal maxilla in relation to the anterior and ramus length was slightly decreased. The
cranial base. anterior facial heights were almost normal while
the posterior facial height was slightly decreased.
The upper and lower incisors were protrusive in
relation to their apical bases with decreased
interincisal angle. The direction of growth
pattern was within normal.
Group three:
It had the most convex profile because of
the combination of protruded maxilla and
retruded mandible in relation to the anterior
cranial base. The cranial base characterized by
significant decrease in the saddle angle that led to
anterior articulation of the condyle, but the
The slight anterior articulation of the highest articular angle brought the mandible in a
condyle and the increased articular angle was not retruded position. The mandibular length was
enough to bring the mandible in its normal significantly decreased, moreover both the ramus
position, thus the shortest mandible showed a length and posterior facial height were the
backward rotation, moreover the gonial angle shortest. This group had the greater backward
was slightly increased and the ramus length was rotation of the mandible (highest mandibular
almost normal. The palatal plane length was plane and basal plane angles), also the gonial
increased and maxillary plane angle was slightly angle was increased, all led to an increased
decreased. It had the highest of each anterior anterior and lower anterior facial heights. The
facial height, lower anterior facial height and length of the maxilla was slightly increased with
posterior facial height. The dentoalveolar pattern almost normal palatal plane angle.
characterized by protrusive mandibular incisors,
normal inclination of the upper incisors and
decreased interincisal angle. The direction of
growth pattern was within normal range.
Group two:
Group two had convex profile due to
maxillary prominence associated with normally
positioned mandible in relation to the anterior
cranial base. The articulation of the condyle was
slightly anterior in relation to the cranial base, in
addition to the presence of the most reduced
articular angle, it tend to bring the mandible in
normal position in spite of the presence of
backward rotation with the most significant
increase in the gonial angle. It expressed the most inclined maxillary and
mandibular incisors in relation to their apical
bases; the interincisal angle was significantly the

Orthodontics, Pedodontics and Preventive Dentistry140

J Bagh College Dentistry Vol. 23(3), 2011
least as compared to other groups. Significant
vertical direction of growth can be seen in this
group.
Group four:
Individuals were characterized by a
markedly retruded profile as both the maxilla and
the mandible are farther back beneath the
anterior cranial base. It was the only group which
showed posterior articulation of the condyle with
a significant decrease in the mandibular length
which led to the most retruded mandible; the
ramus length was also slightly reduced.
The mandibular plane angle was slightly
increased, while the basal plane angle, articular
angle and the gonial angle was almost normal.
The maxillary length was the shortest as
compared to other class II groups with extreme
steepness. The anterior, lower and posterior
facial heights were slightly decreased with
almost normal upper anterior facial heights. The
dentoalveolar pattern characterized by lingual
tipping of the maxillary incisors and protrusive
lower incisors, the interincisal angle was almost
normal, but it was the highest as compared to
other class II groups. The growth pattern is
within normal.
Group five:
It characterized by a prognathic skeletal
relationship; both the maxillary and mandibular
bases are anterior in relation to the anterior
cranial base. The most significant anterior
articulation of the condyle with the longest
mandibular length made the mandible to appear
prognathic which synchronized with the largest
maxillary increment.
The mandibular and palatal plane angles were
significantly decreased which mean forward
rotation of the mandible and maxilla which is a
unique feature for this group, while the gonial
and the basal plane angles were almost normal.
This group revealed the highest posterior facial
height with the lowest anterior, upper and lower
facial heights. The upper and the lower incisors
were protrusive with decrease in the interincisal
Orthodontics, Pedodontics and Preventive Dentistry141
The morphology and texture
angle. The direction of growth pattern was
significantly horizontal.
The cranial base
The saddle angle in the group four showed
non significant increase compared with the
control group, which agreed with Dhopaktar (11);
Al-Azzawi (14) and Sanders et.al (15), group three
and five had significant reduction in this angle,
while group one and two showed no significant
reduction, which came in agreement with Bjork
(8)
; Wells (16); Kerr (17); Al-Saffar (18); and Al-
Assal (19).
The anterior cranial base length (SN)
showed no significant difference between all
class II groups and control group, this was in line
with Al-Saffar (18) and disagreed with Dhopatkar
(11)
.
The posterior cranial base length (SAr) in
the control group had no significant difference
with all class II groups, which came in agreement
with Al-Saffar (18), but disagreed with Al-Sahaf
(6); Rakosi (7) and Dhopatkar (11) whose found
decrease in the lateral cranial base length in
skeletal class II.
The maxilla
In the present study, the length of the
maxilla in all class II groups found to have no
significant difference compared with the control
group which came in agreement with Al-Sahaf (6)
and Al-Assal (19).
The mean value of SN-PP angle showed no
significant reduction in group one, two and three
compared with control group which is agreed
with Al- Assal (19), group four had significant
increase in this angle, on the other hand group
five showed significant decrease which agreed
with Palomo et al. (20).
The mandible
The mean value of the mandibular length
(MP) in group one, three and four was
significantly reduced, this agreed with Sanders
et. al (15), while group two and five had no
significant difference, this came in agreement
with Dhopatkar (11).
J Bagh College Dentistry
Group one and five had no significant
difference in ramus length, while other groups
had reduced ramus length but in non significant
level that came in agreement with Al-Assal (19)
and Sanders et. al (15).
The SN-MP angle in group one, two and four
showed no significant increase compared with
the control group, that agreed with Al- Assal (19),
but it was increased significantly in group three
which came in agreement with Sayın et. al (21).
Moreover the mean value of this angle in group
five was significantly less than the control group
which may be due to prognathism of the
mandible that lead to forward rotation of the
mandible and flatter mandibular plane angle in
this group.
In this study there was no significant
difference in all class II groups compared with
the control group in gonial angle which is agreed
with and Al- Assal (19).
The Articular angle was significantly higher
in group three than the control group, while the
mean value in group one was non significantly
higher which came in agreement with Rakosi (7)
and Al- Assal (19).
Facial heights
Upper anterior facial height (UAFH) in
group one and four had nearly similar mean
values of control group; while in group two,
three and five was non significantly reduced, this
came in agreement with Kinaan et al. (22).
Lower anterior facial height (LAFH) was
non significantly decreased in group four and
five, while group one, two and three had no
significant increase which agreed with Isik et. al
(23)
.
The mean value of the anterior facial height
(AFH) showed non significant reduction in group
four and five, which came in agreement with Al
Sahaf (6) and Kinaan et al. (22). Group two showed
almost the same mean value as control group,
while group one and four had slight increase
which agreed with Isik et. al (23).
The mean value of the posterior facial
height (PFH) was no significantly less in the
group two, three and four that’s agreed with
Kinaan et al. (22) and Sayın et. al (21). Group one
and five which showed no significant increase
were agreed with Al Sahaf (6).
RREFRENCES
1. Foster TD. A textbook of orthodontics. London:
Blackwell, 1982.
2. Rosenblum RE. Class II malocclusion: mandibular
retrusion or maxillary protrusion. Angle Orthod 1994;
65: 49-62.
Orthodontics, Pedodontics and Preventive Dentistry142
Vol. 23(3), 2011 The morphology and texture
3. Riedel RA. The relation of maxillary structures to
cranium in malocclusion and in normal occlusion.
Angle Orthod 1952; 22:142–5.
4. Neela PK, Mascarenhas R, Husain A. A new saggital
dysplasia indicator: the Yen angle. World J Orthod
2009; 10(2):147-51.
5. Baik CY, Ververidou M. A new approach of assessing
sagittal discrepancies: The Beta angle. Am J Orthod
Dentofac Orthop 2004; 126:100–5.
6. Al-Sahaf NH. Cross-sectional study of cephalometric
standards and associated growth changes. A master
thesis, Department of Pedodontics, Orthodontics, and
Preventive Dentistry, University of Baghdad, 1991.
7. Rakosi T. An atlas and manual cephalometric
radiography. London: Wolfe medical publications Ltd.
1982, p. 7, 35-45, 66-67,113-116, 135.
8. Björk A. The face in profile: An anthropological x-ray
investigation on Swedish children and conscripts.
Svensk Tandl Tidskr 1947.
9. Caufield PW. Tracing technique and identification of
landmarks. In Jacobson A (ed). Radiographic
cephalometry from basics to video imaging. Chicago:
Quintessence publishing Co. 1995; p. 60.
10. Dibbets JM. Morphological associations
between the Angle classes. Eur J Orthod 1996; 18(2):
111-8.
11. Dhopatkar A, Bhatia S, Rock P. An
investigation into the relationship between the cranial
base angle and malocclusion. Angle Orthod 2002;
72(5): 456-63.
12. Donovan RW. Recent research for diagnosis.
Am J Orthod 1954; 40(8): 591-609.
13. Biggerstaff RH, Allen RC, Tuncay OC,
Berkowitz J. A vertical cephalometric analysis of the
human craniofacial complex. Am J Orthod 1977;
72(4): 397-405.
14. Al-Azzawi. The position of glenoid fossa in
different skeletal patterns and its relation to the
functional occlusal plane. A master thesis, Orthodontic
Department, University of Baghdad, 2006.
15. Sanders A, Paul H, William P, Neacec F,
Ravindra N. Skeletal and dental asymmetries in Class
II subdivision malocclusions using cone-beam
computed tomography. Am J Orthod Dentofac Orthop
2010; 138:542.e1-542.e20.
16. Wells DLA. Multivariate cephalometric study
of Class II, division 2 malocclusion. Master's Thesis,
University of Michigan, Ann Arbor 1970.
17. Kerr WJ. A longitudinal cephalometric study of
dento-facial growth from 5to 15 years. Brit J Orthod
1979; 6: 115-21.
18. Al-Saffar TH. The condylar position in skeletal
class I and class II.A master thesis. Orthodontic
Department, University of Baghdad, 2004.
19. Al- Assal ADR. A three dimensional
cephalometric analysis of skeletal Class I and II Iraqi
patients aged 15 – 20 years in Baghdad city. A master
thesis, Orthodontic Department, University of
Baghdad, 2006.
20. Palomo JM, Hunt DW, Hans MG, Broadbent
BH. A longitudinal three dimensional sizo and shape
comparison of untreated class (I) and Class (II)
subjects. Am J Orthod Dentofac Orthop 2005; 127(5):
584-91.
21. Sayın M, Tu¨rkkahraman H. Cephalometric
Evaluation of Nongrowing Females with Skeletal and
J Bagh College Dentistry Vol. 23(3), 2011 The morphology and texture

Dental Class II, division 1 Malocclusion Angle Orthod
2005; 75:656–60.
22. Kinaan BK, Ali FA, Al-Aloosy AS.
Characteristics of skeletal one and two: A
cephalometric study on 9 and 10 years Iraqi children.
Iraqi Dent J 1993; 16:23-32.
23. Isik F, Nalbantgil D, Sayinsu K, Arun T. A
comparative study of cephalometric and arch width
characteristics of Class II division 1 and division 2
malocclusions. Eur J Orthod 2006; 28:179–83.

Table 1. Descriptive Statistics of the study groups for angular and linear measurements

Control
Group1 Group2 Group3 Group4 Group5
Variables Group
p-
Mean Mean Mean Mean Mean Mean
value
NSAr 123.31 123.72 120.66 126.71 120.11 124.16 .000
SArGo 145.25 141.83 149.16 142.57 142.94 143.29 .003
Angular SNPP 7.87 7.72 7.50 10.33 5.82 8.50 .001
measurements SNMP 33.50 33.83 35.55 32.90 26.64 31.29 .000
PPMP 25.75 26.16 28.33 22.71 21.05 22.54 .001
SNAB 65.50 68.50 64.05 65.19 72.00 73.79 .000
NAPog 169.25 166.83 163.44 172.76 170.64 175.37 .000
Go 124.87 128.16 125.77 123.66 124.05 123.79 .168
Sum of post.
393.43 393.72 395.61 392.95 387.11 391.25 .000
angles
U1PP 110.12 112.77 115.22 108.33 114.05 110.50 .122
Dental L1MP 101.06 100.94 102.83 101.38 101.41 98.87 .482
U1L1 124.93 120.05 115.55 128.00 123.94 128.54 .002
SN 68.64 68.05 67.95 68.53 68.30 67.82 .976
SAr 34.63 33.10 33.41 33.80 35.42 34.07 .397
PP 50.54 51.00 50.07 49.79 51.39 48.53 .286
MP 64.36 67.16 65.40 64.49 69.31 68.89 .004
Linear
RL 45.83 44.05 42.98 44.74 46.04 45.68 .362
measurements
UAFH 50.39 49.22 49.20 50.8 48.06 50.02 .246
LAFH 64.32 62.05 63.31 59.98 59.64 61.34 .064
AFH 114.13 111.32 112.88 110.78 107.76 111.41 .135
PFH 76.42 73.13 72.96 73.85 76.47 74.87 .432

Orthodontics, Pedodontics and Preventive Dentistry143

J Bagh College Dentistry Vol. 23(3), 2011 Inter-arch tooth size

Inter-arch tooth size discrepancy for Sulaimani population

with class II malocclusion
Trefa M. Ali, BDS, M.Sc (1)

ABSTRACT
Background The present study aimed to investigate the correlation between anterior and overall tooth size
discrepancies for Class II (division 1 and division 2) malocclusion in Sulaimani population, assessing the mesiodistal
width of 12 permanent teeth upper and lower from right first permanentmolar to the other and explore the possible
significant gender differences.
Materials and Methods The sample was collected from patient attending orthodontic clinic in the college of
dentistry, Sulaimani University aged 14 – 25 years old, the materials consisted of stone casts of the dentition of 53
pateints (males and females) , 30 of them class II division 1 ( 15 male and 15 female) and the remaining 23 casts were
class II division 2 ( 12 male , 11 female) who presented with complete eruption of permanent mandibular incisors,
canines, premolars and first molars , as well as maxillary canines , premolars and first molars.
Results The overall and anterior ratios were consistently larger in males than in females but statistically non significant
also there were no significant differences in comparison between class II div.1 and class II div.2 concerning both
overall and anterior ratios.
Conclusion Intermaxillary tooth size ratios may vary in different malocclusion types and may, to some degree,
contribute to the severity of a malocclusion and an appropriate relationship of the mesiodistal widths of the maxillary
and mandibular teeth favors optimal post-treatment results. So these results improved that the Bolton analysis is
important and should be considered when diagnosing, planning, and predicting prognosis in clinical orthodontics.
Key Words: Tooth size discrepancy, Bolton ratio, Sulaimani population. (J Bagh Coll Dentistry 2011;23(3): 144-148).
‫ﺍﻟﺨﻼﺼﺔ‬
‫ﻡ‬‫ﻘﻴ‬‫ ﻴ‬،‫ ﺍﻟﺜﹼﺎﻨﻲ ﻤﻥ ﺍﻷﻁﺒﺎﻕ ﺒﻘﺴﻤﻴﻪ ﺍﻻﻭل ﻭﺍﻟﺜﺎﻨﻲ ﻓﻲ ﺴﻜﺎﻥﹺ ﻤﺤﺎﻓﻅﺔ ﺍﻟﺴﻠﻴﻤﺎﻨﻴﻪ‬‫ ﺤﺠﻡﹺ ﺍﻷﺴﻨﺎﻥ ﺍﻷﻤﺎﻤﻴﻪ ﻭﺍﻟﺨﻠﻔﻴﻪ ﻟﻠﺼﻨﻑ‬‫ ﺒﻴﻥ ﺘﻨﺎﻗﻀﺎﺕ‬‫ﻱ ﺍﻹﺭﺘﺒﺎﻁ‬‫ﺃﻥ ﻫﺩﻑ ﺍﻟﺩﺭﺍﺴﺔﹸ ﺍﻟﺤﺎﻟﻴﺔﹸ ﻫﻭ ﻟﺘﹶﺤﺭ‬
‫ ﻥ‬‫ﻌﺕﹾ ﻤ‬‫ﻤ‬‫ﻨﺔ ﺠ‬‫ ﺍﻟﻌﻴ‬،‫ ﺍﻟﻤﺤﺘﻤﻠﺔ‬‫ﺔ‬‫ ﻟﺒﻴﺎﻥ ﺍﻟﻨﺴﺒﺔ ﺍﻻﻤﺎﻤﻴﻪ ﻭﺍﻟﺨﻠﻔﻴﻪ ﻭ ﺒﻴﺎﻥ ﺇﺨﺘﻼﻓﺎﺕﹶ ﺍﻟﺠﻨﺱﹺ ﺍﻟﻬﺎ ﻤ‬Bolton ratio ‫ ﺩﺍﺌﻡﹺ ﻤﻥ ﺍﻟﻔﻜﻴﻥ ﺍﻟﻌﻠﻭﻱ ﻭ ﺍﻟﺴﻔﻠﻲ ﻭ ﺃﻋﺘﻤﺎﺩ ﻤﻌﺎﺩﻟﺔ‬‫ ﺴﻥ‬12 ‫ﻋﺭﺽ‬
‫ ﺴﻨﻪ ﻤﻥ ﺍﻟﺫﻴﻥ ﺍﺴﺘﻭﻓﻭﺍ ﺍﻟﻤﻭﺍﺼﻔﺎﺕ ﺍﻟﻤﻁﻠﻭﺏ‬25-14 ‫ ﻤﺭﻴﺽ ﺒﻌﻤﺭﹺ‬53 ‫ ﺠﺎﻤﻌﺔ ﺍﻟﺴﻠﻴﻤﺎﻨﻴﻪ ﺤﻴﺙ ﺘﻡ ﺍﺨﺘﻴﺎﺭ‬،‫ ﻁﺏﹺ ﺍﻷﺴﻨﺎﻥ‬‫ﺔ‬‫ﺍﻟﻤﺭﻀﻰ ﺍﻟﺫﻴﻥ ﻴﺭﺍﺠﻌﻭﻥ ﻋﻴﺎﺩﺓﹶ ﺘﻘﻭﻴﻡ ﺍﻷﺴﻨﺎﻥ ﻓﻲ ﻜﻠﻴ‬
‫ ﻭ ﻗﻴﺎﺱ ﺍﺒﻌﺎﺩ ﺍﻻﺴﻨﺎﻥ ﻗﺩ‬،(‫ ﺃﻨﺜﻰ‬11 ،‫ ﺫﻜﺭ‬12) 2 ‫ ﻜﹶﺎﻨﺕﹾ ﺼﻨﻑﹶ ﺍﻟﺜﹼﺎﻨﻲ ﻗﺴﻡ‬23‫ ﺃﻨﺜﻰ( ﻭﺍﻟﻘﻭﺍﻟﺏ ﺍﻟﺒﺎﻗﻴﺔ ﺍﻟـ‬15‫ ﺫﻜﺭ ﻭ‬15) 1 ‫ ﻤﻨﻬﻡ ﺼﻨﻑ ﺍﻟﺜﹼﺎﻨﻲ ﻗﺴﻡ‬30 ، ‫ﻟﻠﺩﺭﺍﺴﺔ )ﺫﻜﻭﺭ ﻭﺇﻨﺎﺙ‬
‫( ﺒﻌﺩ ﺠﻤﻊ ﺍﻟﺒﻴﺎﻨﺎﺕ ﺘﻡ ﺘﺤﻠﻴﻠﻬﺎ ﺒﻭﺍﺴﻁﺔ ﺍﻟﺤﺎﺴﻭﺏ‬Bolton ration 1958 ) ‫ﺘﻤﺕ ﻋﻠﻰ ﺘﻤﺎﺫﺝ ﺩﺭﺍﺴﻴﺔ ﺒﺎﺴﺘﻌﻤﺎل ﻤﻘﻴﺎﺱ ﺴﻨﻲ ﺍﻟﻜﺘﺭﻭﻨﻲ ﻭ ﻨﺴﺒﺔ ﻗﻴﺎﺱ ﺍﻻﺴﻨﺎﻥ ﺤﻠﻠﺕ ﺒﺎﺴﺘﻌﻤﺎل‬
. ‫ﻴﻥ ﺍﻻﻭل ﻭﺍﻟﺜﺎﻨﻲ‬‫ﺔﹶ ﺒﺎﻟﻤﻘﺎﺭﻨﺔ ﺒﻴﻥ ﺍﻟﺼﻨﻔ‬‫ ﺍﻹﻨﺎﺙ ﻭ ﻫﻨﺎﻙ ﺃﻴﻀﺎ ﺇﺨﺘﻼﻓﺎﺕﹶ ﻫﺎﻤ‬‫ﻥ‬‫ﺏ ﺍﻷﻤﺎﻤﻴﻪ ﻭ ﺍﻟﺨﻠﻔﻴﻪ ﺃﻜﺒﺭ ﺒﺜﺒﺎﺕ ﻓﻲ ﺍﻟﺫﻜﻭﺭﹺ ﻤ‬‫ﺴ‬‫ﺍﻟﻤﺒﺭﻤﺞ ﺍﺤﺼﺎﺌﻴﺎ ﻭ ﻜﺎﻨﺕ ﻨﺘﺎﺌﺞ ﺍﻟﻨ‬

INTRODUCTION
Orthodontic treatment comprises different and because that the patients with interarch tooth
phases with unique characteristics and challenges. size discrepancies require either removal or
The orthodontic “finishing”phase is recognized addition of tooth structure to open or close spaces
for the multitude of details necessary to achieve in the opposite arch, it is important to determine
an excellent result. In some cases, the finishing the amount and location of tooth size discrepancy
phase is very difficult, requiring the production of before starting treatment (7). In contrast to the
complicated biomechanical forces to reach a progress that has been made in recent decades in
satisfactory orthodontic solution. Early pioneers the field of orthodontic treatment, especially in
of orthodontics realized the importance of the fixed appliances, diagnostic aspects have not
harmonious relationship between the teeth in the undergone such extensive development. Essential
same arch and between arches. This phase of the diagnostic elements such as tooth-size harmony
orthodontic problem had been studied and cephalometric analysis have not been the
quantitatively by different investigators (1-5). The focus of research, and this has led to few studies
crown size of the teeth especially the mesiodistal being published in this field (5). Orthodontists
width is one of the significant attribute of the have used several methods to detect interarch
normal occlusion and it is also important to study tooth size discrepancies in patients presenting for
the dental characteristics of the population so as to orthodontic treatment. Most methods, including
trace the on going process of evolutionary trend Kesling’s diagnostic setup(8), Neff’s anterior
(6)
. A specific dimensional relationships must exist coefficient(9) are not commonly used. The Bolton
between the maxillary and mandibular teeth to analysis (1-2) based on the ratios between the
ensure proper interdigitation, overbite, and overjet mesiodistal tooth diameter sums of the
mandibular and the maxillary dentitions, remains
the most recognized and widely used method for
detecting interarch tooth size discrepancies (10-12).
The Bolton analysis is considered to be a good
indicator for evaluating the degree of
(1) College of dentistry, univ. of Dohuk intermaxillary tooth-size harmony, but the

Orthodontics, Pedodontics and Preventive Dentistry144

J Bagh College Dentistry Vol. 23(3), 2011
possibility of ethnic variation of these values
should be examined. Thus, the aim of this study
was to calculate both the anterior and overall
ratios of mandibular and maxillary tooth sizes for
a kurdish sample of class II malocclusion and to
compare these ratios with the data from the
Bolton and Arabic studies(4). Discovery during the
finishing stages could lead to embarrassing delays
in the completion of treatment, or even worse, to a
compromised result. Therefore, the ability to
analyze the proportionality of the maxillary and
mandibular teeth is an important diagnostic tool
and one that would be best used at the initial
diagnostic stage. Bolton, (1958) published his
work on interpreting MD tooth size diameter and
their effect on occlusion, Bolton selected 55 cases
with excellent occlusion, 44 cases had been
treated orthodonticaly (non extraction). He
concluded that an overall ratio of 91.3 and an
anterior ratio of 77.2 were necessary for proper
coordination of the maxillary and mandibular
teeth. Dahlberg, (13) in early 20th century explained
the role of genes and their possible effect on
dental characters where genes were responsible
for the occurrence of a certain dental trait in a
population and its absence in another population.
He pointed out that because genes are not freely
exchanged between populations (due to
geographic, language, religious, and other social
reasons) the frequencies and manifestations of
dental characters are not the same in between
various ethnic groups. Potter et al.(14) believed that
the inheritance of mesiodistal diameter and dental
occlusion is according to polygenic system where
the action of many genes together with
environmental factors will give the final result
(phenotype) of the dental trait. Doris et al.(15)
found that: 1-Tooth morphology is under rigid
genetic control. 2-The genes that determine
whether or not the morphologic traits will be
expressed are independent of each other. Other
studies were directed towards the effect of
environmental factors on dental characters like:
Bailit, (16) found that the environmental factors
Cleary influence tooth size, but little is known
about specific environmental conditions that are
associated with the size of the tooth. Some data
suggest that children of lower socioeconomic
class have smaller teeth but the evidence is not
very convincing. The evidence on other factors
such as climate, systemic diseases and nutrition
are equally ambiguous. If these environmental
associations indeed exist, they must be of
relatively small magnitude. Hikmat and
Farhan,(17) an augmented environmental observed
effect on dental occlusion in general as growth
and development proceeded from the primary to
Orthodontics, Pedodontics and Preventive Dentistry145
Inter-arch tooth size
the mixed dentition stage. Nevertheless, non
genetic environmental factors play an important
role in the prenatal period as well. Among these
the maternal effects have a major part. Some
investigators (18-21) have noted a secular trend
toward an increase in tooth size with succeeding
generations, their data showed that primitive
civilization exhibited a significant degree of wear
or attrition, probably the result of more vigorous
mastication of harder food stuff than is commonly
associated with modern man. Therefore, they
found that teeth dimensions of sons were greater
than those for girls.
Classification of Malocclusion
The classification of static, morphologic occlusion
and malocclusion has been of interest to dentistry
for at least a century because this classification
plays several important roles(22):
1- classification aids in the diagnosis and treatment
planning of malocclusions by orienting the
clinician to the type and the magnitude of the
problems and possible mechanical solutions to the
problems.
2- classification facilitates communication
between specialists.
Angle, (1899) described three groups:
1) Class I Or Neutrocclusion:
The mesiobuccal cusp of the upper first molar
occludes with the mesiobuccal groove of the
lower first molar, in practice discrepancies of up
to half a cusp width either way also included in
this category.
2) Class II Or Distocclusion:
The mesiobuccal cusp of the lower first molar
occludes distal to class I position, this is also
known as post normal relationship.
3) Class III Or Mesiocclusion :
The mesiobuccal cusp of the lower first occludes
mesial to class I position, this is also known as
prenormal relationship.
MATERIALS AND METHODS
The sample of the study was collected from
patient attending orthodontic clinic in the college
of dentistry, Sulaimani University aged 14 – 25
years old. Each of them were seated in upright
position and examined extraorally to identify the
skeletal relation according to Foster method and
then intraorally to identify the molar relation
according to Angle’s classification, they should
be class II malocclusion (extraorally and
intraorally) otherwise it was excluded. After
examining more than 200 patients 53 cases were
selected, The materials consisted of stone casts of
the dentition of 53 patients (males and females) ,
30 of them class II division 1 (15 male and 15
female) and the remaining 23 casts were class II
J Bagh College Dentistry Vol. 23(3), 2011
division 2 (12 male, 11 female) who presented
with complete eruption of permanent mandibular
incisors, canines, premolars and first molars , as
well as maxillary canines, premolars and first
molars, presented with no proximal caries or
fillings, morphological anomalies, missing teeth,
proximal or occlusal abrasion, or bruxism. The
mesiodistal width of a tooth was obtained by
measuring the greatest distance between contact
points on the proximal surfaces. A pointed Digital
Vernier Caliper (0.02 mm accuracy) will be
inserted from the buccal surface with instrument
held at right angle to the long axis of the crown (3).
The teeth measured are the mandibular permanent
central and lateral incisors, the maxillary and
mandibular permanent canines, the maxillary and
mandibular premolars and maxillary and
mandibular 1st permanent teeth (23). The following
measurements have been undertaken: The MD
width of the 12 maxillary teeth (first molar to first
molar) were totaled and compared with the sum
derived by the same procedure carried out on the
12 mandibular teeth, the ratio derived between the
two is the percentage relationship of mandibular
arch length to maxillary arch length. The same
procedure was carried out to analyze the six
anterior teeth from canine – canine according to
Bolton analysis as followed:
Overall ratio= Sum mandibular [12] / Sum
maxillary [12] X 100
Anterior ratio =Sum mandibular [6]/ Sum
maxillary [6] X 100
Statistical analysis of the collected data was
performed using SPSS soft ware version 12.
RESULTS
Table 1 shows means, standard deviation,
minimum, maximum and ranges for tooth size
analysis for both ratios for males and females
separately for both types of class II malocclusion.
And reveal there were no significant differences
between male and female ratios (anterior and
overall ratios) for both types of malocclusions
(division 1 and division 2), table 2 shows the
means, standard deviations and ranges for tooth
size ratio observed for combined males and
females’ sample, so that mean anterior ratio for
REFERENCES
1- Bolton A. Disharmony in tooth size and its relation to
the analysis and treatment of malocclusion. Angle
Orthod1985; 28: 113-30.
2- Bolton WA. The clinical application of a tooth size
analysis. Am J Orthod 1962; 48: 504-29.
3- Sofia SH. Mesiodistal crown of permanent teeth and
prediction chart mixed dentition analysis. Master
thesis, Mosul University.Iraq.1996
Orthodontics, Pedodontics and Preventive Dentistry146
Inter-arch tooth size
class II division 1 was 78.594, and overall ratio
was 92.106, again there were no significant
differences in both ratios.
DISCUSSION
The overall and anterior ratios were
consistently larger in males than in females
regardless of race, but not significant and this
come in accordance with Nie and Lin, (24) that
found :when tooth size ratios were compared,
there were no significant differences between
class II division I and class II division 2, also they
suggest that the tooth size discrepancy between
maxillary and mandibular teeth may be one of the
important factors in the cause of malocclusions,
especially in class II and class III malocclusions.
Smith et al, (7) concluded that there were
significant differences in the overall and anterior
ratios between whites, blacks, and Hispanics
suggest that population specific standards are
necessary for clinical assessment.
Our result is in contrast to Smith et al; (7) who
found significant gender differences for both
ratios. This difference may be attributed to the
difference in the ethnic group, age group variation
and sample size. Crosby and Alexander (11) found
that there were no significant differences among
class II division 1, and class II division 2 while
another study done on Croatian subject (25) reveal
that there were significant gender difference in
anterior ratio.
Salem reported a larger anterior and overall
ratio for the both types of class II malocclusion in
an Arab sample in Baghdad city since , anterior
and overall ratio for class II div.1 was 78.04 and
92.08 while for class II div.2 was 78.743 and
91.603 (4).
Finally, Intermaxillary tooth size ratios may vary
in different malocclusion types and may, to some
degree, contribute to the severity of a
malocclusion(26) and an appropriate relationship of
the mesiodistal widths of the maxillary and
mandibular teeth favors optimal post-treatment
results (25). So these results improved that the
Bolton analysis is important and should be
considered when diagnosing, planning, and
predicting prognosis in clinical orthodontics.
4- Saleem EA. Permanent tooth size ratio assessment
for a sample of Iraqi patient aged 14-25 years with
different malocclusion types.Master thesis Baghdad
University ,Iraq.2003
5- Abduhl WN, Splieth CH, Schwahn C, Khurdaji M.
Standardizing Interarch Tooth-Size Harmony in a
Syrian Population ,The Angle Orthodontist 2004; 75:
6: 996–9.
6- El-Faituri HN, Kapoor AK. Mesio-distal crown
width in Libyan with normal occlusion. Arab Dent J
1995; 3: 19-25.
J Bagh College Dentistry Vol. 23(3), 2011 Inter-arch tooth size

7- Smith SS, Buschang PH, Watanabe E. Interarch
tooth size relationships Of 3 populations: “Does
Boltons analysis apply”. Am J Orthod Dentofac
Orthop 2000; 117: 169-74.
8- Kesling HD. The philosophy of the tooth positioning
appliance. Am J Orthod 1945; 31:297-340.
9- Neff CW. Tailored occlusion with the anterior
coefficient. Am J Orthod.1949; 35: 309-14.
10- White LW. The clinical use of occlusograms. J Clin
Orthod 1982; 16:92-103.
11- Crosby DR, Alexander CG. The occurrence of tooth
size discrepancies among different malocclusion
groups. Am J Orthod dentofac Orthop 1989; 95:457-
61.
12- Freeman JE, Maskeroni AJ, Lorton L. Frequency of
Bolton tooth –size discrepancies among patients. Am
J Orthod Dentofac Orthod1996; 7:110-24.
13- Dahlberg A. The changing dentition of man. J Am
Dent Assoc 1945; 32: 676-90.
14- Potter RH, Nance WE, Dauis WB. A twin study on
dental dimension II. Independent genetic
determination. Am J phys Anthropal 1976; 44: 397-
412.
15- Doris JM, Bernard BW, Kuftinec MM, Stom D. A
biometric study of tooth size and dental crowding.
Am J Orthod 1981; 79:326–36 .
16- Bailit HL. Dental variation among populations: an
anthropologic view. Dent Clin North Am 1975; 19:
125-39.
17- Hikmat K, Farhan N. A study of dentition of
monozygotic twins between early deciduous and
latest mixed dentition. The ninth congress of Arab
Dental Assoc. 27-30 March.1975; Cairo-lecture.
18- Beresford JS. Tooth size and class distinction. Dent
Pract.1969; 20: 113-120.
19- Lavelle CLB. Variation in the secular changes in the
teeth and dental arches. Angle Orthod.1973; 43:412-
21.
20- Sanin C, Savara BS. Factors that affect the alignment
of the mandibular incisors (a longitudinal study). Am
J Orthod 1973; 64: 248-57.
21- Arya BS, Savara BS, Thomas D. Relation of sex and
occlusion to mesiodistal tooth size. Am J
Orthod.1974; 66:479-86.
22- Katz MI. Angle classification revisited: Is current
use reliable. Am J Orthod.1992; 102: 173-9.
23- AL-Rashdan MS. Odontometric study of maxillary
and mandibular permanent teeth in relation to arch
dimension in Iraqi sample. Master thesis, Baghdad
University, Iraq.1996
24- Nie Q, Lin J. Comparison of intermaxillaty tooth
size discrepancies among different malocclusion
groups. AM J Orthod Dentofac Orthop 1999; 116:
539-44.
25- Mihovil Strujić, Sandra Anić-Milošević, Senka
Meštrović and Mladen Šlaj :Tooth size discrepancy
in orthodontic patients among different malocclusion
groups, Eur J Orthod. 2009; 31 (6): 584-9.
26- Hüsamettin Oktay and Esengül Ulukaya
:Intermaxillary tooth size discrepancies among
different malocclusion groups. Eur J Orthod 2010; 32
(3): 307-12.

Table 1: Descriptive statistics of the tooth size ratio in both males and females in class II division
1 and class II division 2 groups.
Standard
Tooth Sex Mean Minimum Maximum Range
Deviation
Ratio
Male 91.453 1.714 89.029 93.305 4.276
Cl II div.1
Female 91.322 1.28 89.553 93.683 4.13
Overall Ratio
Male 91.274 1.584 89.348 93.08 3.732
Cl II div.2
Female 91.44 1.38 89.64 94.29 4.65
Male 78.49 1.685 76.19 81.379 5.189
Cl II div.1
Female 77.207 3.149 72.474 81.962 9.488
Anterior Ratio
Male 78.152 1.86 75.364 80.348 4.984
Cl II div.2
Female 78.35 2.46 73.8 81.2 7.4

Table 2: Tooth size ratio for combined males and females in class II division 1 and class II
division 2 groups.
Tooth Standard
Mean Minimum Maximum Range t-test P value
Ratio Deviation
Cl II div.1 91.387 1.487 89.029 93.683 4.654
Overall Ratio 0.078 0.937
Cl II div.2 91.35 1.462 89.348 94.29 4.942
Cl II div.1 77.848 2.566 72.464 81.962 9.498
Anterior Ratio 0.661 0.511
Cl II div.2 78.249 2.11 73.8 81.2 7.4
All the measurements are statistically not significant at p> 0.05

Orthodontics, Pedodontics and Preventive Dentistry147

J Bagh College Dentistry Vol. 23(3), 2011 Inter-arch tooth size

Table 3: Comparison of the tooth size ratio between males and females in class II division 1 and
class II division 2 groups.
Malocclusion type Tooth Male Female P-value
T-value
Ratio Mean S.D. Mean S.D. *
Overall Ratio 91.453 1.714 91.322 1.28 0.233 0.817
Class II division 1
Anterior Ratio 78.49 1.685 77.207 3.149 1.361 0.184
Overall ratio 91.274 1.584 91.44 1.38 0.306 0.761
Class II division 2
Anterior ratio 78.152 1.86 78.35 2.46 0.241 0.810
* All the measurements are statistically not significant at p> 0.05

Orthodontics, Pedodontics and Preventive Dentistry148

J Bagh College Dentistry Vol. 23(3), 2011 The characteristic features

The characteristic features of skeletal class III in Iraqi

adult orthodontic patient
Wurood KH. Al-lehaibi, B.D.S., M.Sc. (1)
Nagham Al-Mothaffar B.D.S., MSc. (2)

ABSTRACT
Background: Skeletal class III malocclusion is one of the dentofacial anomalies which associated with deviation in
the sagittal relationship of maxilla and mandible. This study performed to determine the characteristic features of
skeletal class III compared with skeletal class I.
Materials and methods: Skeletal class III sample included 100 pretreatment digital lateral cephalometric radiographs
(18-29) years which selected on the basis of Beta angle [> 35°] and divided into five groups according to location of
maxilla and mandible in relation to the anterior cranial base (SNA and SNB angles). Another 45 radiographs were
selected as control group (normal SNA, SNB angles, Beta angle 27°-35°). Fourteen angular and eight linear
measurements digitized and recorded using AutoCAD 2010 computer program.
Results and Conclusions: In comparison with skeletal class I, skeletal class III had: Shorter anterior cranial base length,
more obtuse gonial angle, no significant difference in the articular angle and upper anterior facial height. Labially
proclined upper incisor and lingually retroclined lower incisor. The prognathism of both jaws was formed 43% of the
sample with the most horizontal growth pattern and protruded profile, the retrognathism of both jaws formed 20%
with the most vertical growth pattern and retruded profile. 17% of the sample had normal positioned maxilla and
protruded mandible and displayed horizontal growth pattern with protruded profile. Pure retruded maxilla formed
12% of the sample and the least type was the combined maxillary retrognathism and mandibular prognathism (8%);
both showed vertical growth pattern with protruded profile but extremely obvious in the latest one.
Key words: Skeletal class III, Characteristic features. (J Bagh Coll Dentistry 2011;23(3): 149-155).

INTRODUCTION A recently developed and named the Beta

Class III malocclusion is a subject of interest
and concern to the orthodontist and it has long
been viewed as one of the most severe facial
deformities. Severe class III malocclusion is one
of the most difficult anomalies to understand and
treat (1). Studies conducted to identify the
etiological features of Class III malocclusion
show that the deformity is not constricted to the
jaws but involves the entire craniofacial complex
(2)
. The facial dysplasia which is produced by
growth disharmony may involve size, form and
position of the apical bases (3-5).
In orthodontic diagnosis and treatment
planning, great importance has been attached to
evaluate the sagittal apical base relationship. Any
cephalometric analysis based on either angular or
linear measurements has obvious shortcomings,
which have been discussed in detail by Moyers et
al. (6). Freeman (7) stated that, even before Angle
introduced his classification of malocclusion to
angle which does not depend on any cranial
landmarks or dental occlusion would be
especially valuable whenever previously
established cephalometric measurements, such as
the ANB angle and the Wits appraisal, cannot be
accurately used because of their dependence on
varying factors (8).
It is important to identify whether the
etiology of Class III malocclusion is dental,
functional or skeletal. If the problem is skeletal,
it must be determined whether the cause is
overdeveloped mandible, underdeveloped
maxilla or combination of both (9). So, when
treating Class III patients orthodontically
whether they are growing children or mature
adults, antero-posterior and vertical position of
facial components as well as dental relationship
must be considered so that the excess or
deficiency may be treated where it actually exists
(10).

the profession in the early l900s, the

anteroposterior relationship of mandible to
maxilla was the most important diagnostic
criterion.
(1) MSc Student, orthodontic department, College of dentistry,
Baghdad University.
(2) Professor, Orthodontic department, College of Dentistry,
Baghdad University.
MATERIALS AND METHODS
The sample
Out of 668 collected pretreatment digital true
lateral cephalometric radiographs from the files
of the patients who attended different Iraqi
specialist dental centers, class III skeletal
dysplasia were only identified in 100 radiographs
according to Baik and Ververido (8) (Beta angle
more than 35 ). The control group consisted from
45 pretreatment digital true lateral cephalometric

Orthodontics, Pedodontics and Preventive Dentistry149

J Bagh College Dentistry Vol. 23(3), 2011
radiographs; that had a skeletal class I
relationship (Beta angle 27° - 35°).
The Inclusion Criteria
1. Clear cephalometric radiographs.
2. The samples were adult with an age
ranged between 18-29 years.
3. They had no congenital anatomical
defect (cleft lip and/or palate).
4. All individuals had no previous
orthodontic or surgical treatment.
The method
Cephalometric analysis
Firstly, to identify the individuals with
skeletal class III (the sample) and those with
skeletal class I (the control group), each lateral
cephalometric radiograph was analyzed by using
AutoCAD program to measure the Beta angle
which should be larger than 35° in skeletal class
III and 27°- 35° in skeletal class I.
After importing the picture to the AutoCAD
program, the points were localized, the planes
were determined, and the angles and distances
were measured. The angles were measured
directly as they were not affected by
magnification, while the linear measurements
were divided by scale for each picture to
overcome the magnification.
After measuring the Beta angle, fourteen
angular and eight linear measurements were
recorded for each selected radiograph and all
measurements were put in excel sheet for the
statistical analyses.
Then the sample with class III skeletal
dysplasia was divided into 5 groups according to
the location of the problem; the position of the
maxilla and the mandible in relation to the
anterior cranial base using the SNA and SNB
angles (11); yet, these two angles were normal in
the control group (SNA= 81°-82°; SNB= 78°-
79°) (12) :
Group 1: individuals with normal position of
maxilla and protruded mandible in relation to the
anterior cranial base.
Group 2: individuals with normal position of
mandible and retruded maxilla in relation to the
anterior cranial base.
Group 3: individuals with retruded maxilla and
protruded mandible in relation to the anterior
cranial base.
Group 4: individuals with retruded maxilla and
mandible in relation to the anterior cranial base.
Group 5: individuals with protruded maxilla and
mandible in relation to the anterior cranial base.
Cephalometric Landmarks, Planes, and
Measurements
Orthodontics, Pedodontics and Preventive Dentistry150
The characteristic features
I. Cephalometric Landmarks
1. Point S (Sella): The midpoint of the Sella
turcica (pituitary gland fossa) (13).
2. Point N (Nasion): The most anterior point on
fronto-nasal suture in the median plane (13).
3. Point Ar (Articulare): The point of intersection
of the external dorsal contour of the
mandibular condyle and the temporal bone
(14).
4. Point ANS (Anterior Nasal Spine): The tip of
the anterior process of the maxilla and is
situated at the lower margin of the nasal
aperture (13).
5. Point PNS (Posterior Nasal Spine): This is a
constructed radiological point, the intersection
of a continuation of the anterior wall of the
pterygopalatine fossa and the floor of the
nose. It marks the dorsal limit of the maxilla
(13).
6. Point A (Subspinale): The deepest midline
point on the premaxilla between the Anterior
Nasal Spine and Prosthion (13).
7. Point B (Supramentale): The deepest midline
point on the mandible between Infradentale
and Pogonion (13).
8. Point Pog (Pogonion): It is the most anterior
point on the mandible in the midline (13).
9. Point Me (Menton): The lowest point on the
symphyseal shadow of the mandible seen on a
lateral cephalograms (15).
10. Point Go (Gonion): A point on the curvature
of the angle of the mandible located by
bisecting the angle formed by the lines
tangent to the posterior ramus and inferior
border of the mandible (15).
11. Point Ii (Incisor inferius): The tip of the
crown of the most anterior mandibular
central incisor (13).
12. Point Is (Incisor superius): The tip of the
crown of the most anterior maxillary central
incisor (13).
13. Point Ap 1 (Apicale 1): Root apex of the
most anterior maxillary central incisor (13).
14. Point Ap 1 (Apicale 1): Root apex of the
most anterior mandibular central incisor (13).
15. Point C (The center of the condyle): Found
by tracing the head of the condyle and
approximating its center (8).
II. Cephalometric planes
1. Sella-Nasion plane (S-N).
2. Sella-Articulare plane (S-Ar).
3. Maxillary plane (Max.P).
4. Mandibular plane (MP).
5. Ramus plane (RP).
6. Long axis of the upper incisor (U1).
7. Long axis of the lower incisor (L1).
J Bagh College Dentistry Vol. 23(3), 2011
8. N- A line.
9. N- B line.
10. Facial plane (N- Pog.).
11. Denture base limit (AB plane).
III. Cephalometric measurements
A. Angular measurements
1. Beta angle (8):
The Beta angle is a new measurement for
assessing the skeletal discrepancy between the
maxilla and the mandible in the sagittal plane. It
uses 3 skeletal landmarks:
A point (Subspinale), B point (Supramentale),
the center of the condyle (C)
Next, defining 3 lines:
• Line connecting the center of the condyle C
with B point (C-B line).
• Line connecting A and B points.
• Line from point A perpendicular to the C-B
line.
Finally, measuring the Beta angle which is the
angle between the perpendicular line from point
A to CB line and the A-B line. Its values are:
Class I (27°- 35°), Class II < 27° and Class III >
35.
Figure 1: Beta angle.
2. SNA angle: the anteroposterior position of
maxilla relative to anterior cranial base (13).
3. SNB angle: It is the anteroposterior position of
mandible relative to the anterior cranial base
(13)
. measured from ANS to Me (21).
4. SN plane-Mandibular Plane Angle (SN-MP):
This angle gives the inclination of the
mandible to the anterior cranial base. It is
formed at the point of intersection of the S-N
plane and mandibular plane. This angle can
give an indication to the type of rotation of
the mandible (16).
5. SN plane-Maxillary Plane Angle (SN-Max.P):
The angle of maxillary plane (ANS-PNS)
inclination in relation to anterior cranial base,
it is formed at the point of intersection of the
S-N plane and maxillary plane (17).
6. SN-Pog angle: It represents the anteroposterior
position of the chin relative to the anterior
cranial base (18).
Orthodontics, Pedodontics and Preventive Dentistry151
The characteristic features
7. Gonial Angle (Ar-Go-Me): The angle between
posterior border of the ramus (Ar-Go) and the
mandibular plane (Go-Me) (13).
8. Articulare angle (S-Ar-Go): This angle formed
at the point of intersection of the S-Ar plane
and the Ar-Go plane (13).
9. Inclination of lower incisor (L1/MP): The
angle between long axis of lower incisor and
mandibular plane (13).
10. Inclination of upper incisor (U1/Max.P): The
angle between the long axis of upper incisor
and maxillary plane (19).
11. Inter-incisal angle (U1-L1): The angle
formed by the intersection of the lines
representing the long axes of the most labial
maxillary and mandibular incisors,
posteriorly (11).
12. Basal plane angle (PP-MP): This defines the
angle of inclination of the mandible to the
maxillary base (13).
13. SN- AB plane angle: The angle between the
S-N plane and the AB plane, posteriorly (20).
14. Saddle angle (N-S-Ar): It is the angle
between the anterior and posterior cranial
base (13)
15. Sum of the posterior angles: it’s the sum of
saddle (NSAr), articular (S-Ar-Go) and
gonial angle (Ar-Go-Me) (13).
B. Linear Measurements
1. S-N: A distance from Sella to Nasion (13).
2. S-Ar: A distance from Sella to Articulare (13).
3. Maxillary length: the distance from Anterior
Nasal Spine to Posterior Nasal (19).
4. Mandibular length: the distance from Gonion
to Menton (19).
5. Ramus length: The distance between Ar and
Go (13).
6. Upper anterior facial height (UAFH): It’s
measured from N to ANS (21).
7. Lower anterior facial height (LAFH):
8. Posterior facial height (PFH): measured from
S to Go (21).
Statistical Analyses
1. Descriptive Statistics: Mean and Standard
deviation (SD).
2. Inferential Statistics: Paired sample t-test: for
intra-examiner and inter-examiner calibration,
ANOVA test: for the comparison among the
groups and Least significant difference test LSD
test: for variables that show significant
differences among the study groups in ANOVA
test.
J Bagh College Dentistry Vol. 23(3), 2011
RESULTS AND DISCUSSION
The sample in this study was selected at age
between eighteen and twenty nine years old to
minimize the effect of any remaining skeletal
growth (22) as the majority of facial growth is
usually complete by 16-17 years of age (23).
According to the collected sample with skeletal
class III relationship, different relations were
found between the maxilla and mandible in their
relation to the anterior cranial base. The results
of this study showed that the mandibular skeletal
protrusion is a prominent feature in the majority
of these individuals and this came in agreement
with Horowitz et al. (24), Dietrich (3) and Jacobson
et al. (4).
In the present study most of the individuals
with skeletal class III showed a protrusion of
both maxilla and mandible (43%) in relation to
the anterior cranial base. For the retrusion of both
jaws, it formed 20% of the collected sample. On
the other hand, individuals with normal position
of maxilla and protruded mandible formed about
17% of the collected sample and only 12% of the
collected sample found to have retruded maxilla
and normal position of mandible in relation to the
anterior cranial base. The least type was those
with combined retruded maxilla and protruded
mandible (8%).
The comparison between different groups of
skeletal Class III and skeletal Class I group
showed that there are great differences in the
craniofacial features as manifested in the lateral
cephalometric radiograph. The differences
between the results of the present study and other
studies may be attributed to different sample size,
criteria of sample selection, or ethnic group.
Group one
This group characterized by the normal
position of maxilla and protruded mandible in
relation to the anterior cranial base. It had a
significantly acute saddle angle and short anterior
cranial base; thus makes the mandibular condyle
positioned beyond the normal range in relation to
the cranial base.
Orthodontics, Pedodontics and Preventive Dentistry152
The characteristic features
The SN-MP, PP-MP, Ar-Go-Me and articular
angle were significantly larger; all moved the
mandible in a backward position to reduce the
severity of prognathic feature. The upper incisor
was significantly proclined while the lower was
significantly retroclined. In spite of nearly
unchangeable posterior facial height, the lower
anterior facial height is significantly increased.
This group underwent a horizontal growth
pattern and showed protruded profile.
Group two
This group characterized by the presence of
retruded maxilla and normal position of mandible
in relation to the anterior cranial base. It had a
significantly acute saddle angle with shorter
anterior cranial base and significantly shorter
posterior cranial base; this results in an anterior
and superior articulation of the mandible with the
cranial base. Whereas, the maxillary plane length
was short and retruded; the size of mandible was
within normal range. The SN-MP and PP-MP
were significantly increased and the gonial angle
was significantly more obtuse which led to a
backward and downward rotation of the
mandible and significantly increased lower
anterior facial height, while a slight reduction
was existed in the posterior facial height. In spite
of the minor proclination of upper incisors, a
retroclined lower incisor was significant. This
group exhibited a significant vertical growth
pattern with protruded profile.
Group three
This group characterized by the presence of
retruded maxilla and protruded mandible in
relation to the anterior cranial base. It had an
acute saddle angle and short anterior and
posterior cranial base. The maxillary plane had a
clockwise rotation relative to the anterior cranial
base which led to a significant downward
rotation of the mandibular plane and significantly
increased PP-MP angle; also the gonial angle
showed the most significant obtuse among the
five skeletal classes III groups which exaggerated
the downward rotation of the mandible and led to
a significant increased lower anterior facial
height. In spite of the presence of significant
J Bagh College Dentistry Vol. 23(3), 2011
longer posterior facial height, a significant
vertical growth pattern and significant protruded
profile were evident in this group.
Dentally, it characterized by the presence of
proclined upper incisors with the most significant
retroclined lower incisors; and the interincisal
angle was significantly increased
Group four
This group characterized by the retrusion of
both jaws in relation to the anterior cranial base.
The saddle angle was significantly the largest
among the five skeletal class III groups with
significantly the shortest anterior, posterior
cranial base, maxillary plane and the smallest
mandible, that’s mean this group had small sizes
of the craniofacial structures. As the inclination
of the SN-PP was significantly the largest in this
group, a downward rotation of mandibular plane
was significantly the greatest synchronized with
the presence of a significant larger gonial angle
and significantly shortest posterior facial height
which led to the most significant increase in the
lower anterior facial height. This group had the
most excessive and significant vertical growth
pattern but with a significant retruded facial
profile. The lower incisors were significantly
retroclined while the upper were almost within
the normal range.
Group five
It characterized by the presence of both the
maxillary and mandibular bases anterior to the
anterior cranial base. The anterior cranial base
was significantly short and the posterior cranial
Orthodontics, Pedodontics and Preventive Dentistry153
The characteristic features
base was nearly normal but the presence of the
most significant acute saddle angle among the
other groups led to a further anterior position of
the mandibular condyle relative to the anterior
cranial base. The ramus and mandibular body
length were significantly longer which means
that the mandible is the largest. In spite of the
significant larger gonial angle and the significant
longest posterior facial height, the lower anterior
facial height was kept within normal value unlike
the other skeletal class III groups because the
maxillary plane was tipped in a counter
clockwise direction which synchronized with a
significant upward mandibular rotation. This
group showed the greatest amount of horizontal
growth pattern with the most significant
protruded profile. Dentally, this group had the
most significant proclined upper incisors and the
least retroclined lower incisors.
The Cranial Base
The anterior cranial base (SN) was shorter in all
study groups, whether significant or not, as
compared with the control group. This is came in
agreement with Namankani and Bukhary(25) and
Proffit et al.(26), while this finding disagrees with
Guyer et al.(13) who reported larger value of the
anterior cranial base in class III group.
Posterior cranial base length (SAr) showed a
significant reduction in groups 2 and 4 when
compared with the control group; this is in
accordance with Battagel(2) and Mouakeh(5) but
this result disagrees with Rakosi (13) who found it
was larger in Class III subjects and this is what
was found in group 5 with a no significant
difference.
Lastly, group 1, 2 and 5 showed a significant
reduction in the saddle angle (NSAr) compared
with the control group; this is in agreement with
Battagel (2) who found that this angle was
significantly smaller in Class III which led to
forward condylar position and mandibular
prognathism. In contrast, both group 3 and 4
found to have a no significant difference and this
agreed with Rakosi (13).
The Maxilla
J Bagh College Dentistry Vol. 23(3), 2011 The characteristic features

In the present study, the length of the maxilla Nojima et al. (27). On the other hand, in group 5 it
(PP) found to be significantly shorter only in was significantly larger which came in line with
group 4 when compared with the control group. Horowitz et al. (24).
This comes in line with Namankani and Dentoalveolar Relationship
Bukhary(25), while the other groups revealed a no The maxillary incisors were more proclined
significant reduction. (U1\PP) and the mandibular incisors were
The (SN-PP) showed a highly significant significantly more retroclined (L1\MP) in
difference in group 4 compared with the control skeletal class III groups. This is in agreement
group; this was found by Namankani and with Guyer et al.(10), Battagel(2)and Namankani
Bukhary(25). While groups 1, 2, 3 and 5 showed and Bukhary (25). The interincisal angle (U1\L1)
no significant difference and this agrees with showed significantly larger in group 3 of Class
Guyer et al.(10). III sample than the control group which agreed
The Mandible with Mouakeh(5).
All skeletal class III groups revealed an
increased value of the mandibular body length Table 1: Descriptive Statistics and
(MP) compared with the control group but the comparison among the study groups for the
only significant increase was found in group 5 total measurements
which agreed with Rakosi(13); the other groups Class
Class III
revealed a no significant difference in (MP) I
Variables Control Group Group Group Group Group
length which came in line with Guyer et al. (10). group 1 2 3 4 5 P-value
Mean Mean Mean Mean Mean Mean
The ramus (RL) was significantly longer in SN 68.81 66.31 67.73 67.90 65.91 67.20 .011**
The
group 5 when compared with the control group, Cranial SAr 34.14 32.96 31.91 33.40 31.83 34.63 .012**
this finding was mentioned by Guyer et al.(10), at base NSAro 126.0 121.8 123.6 123.6 126.6 120.4 .000***
The PP 51.76 50.25 49.86 51.30 48.86 51.56 .005**
the same time the no significant difference maxilla SNPPo 8.64 8.94 8.58 10.50 10.70 7.86 .005**
between skeletal class III and skeletal class I in MP 68.64 70.86 69.54 71.18 67.98 72.12 .001***
RL that have been found by Namankani and The
RL 47.89 47.18 48.25 48.11 45.52 50.07 .021*
Goo
Bukhary(25) can be seen in group 1, 2, 3 and 4. mandible
SNMPo
126.2
32.35
130.0
35.35
133.1
38.50
135.5
38.12
135.3
44.65
129.1
29.83
.000***
.000***
The gonial angle was found to be significantly PPMPo 23.60 26.88 30.41 29.25 33.65 22.76 .000***
larger in all skeletal class III groups when Facial
UAFH 50.84 50.62 50.47 51.49 51.51 50.69 .89(NS)
LAFH 63.76 67.21 69.83 68.62 71.71 64.98 .000***
compared with the control group. This angle heights
PFH 77.19 76.67 75.02 78.42 72.54 79.87 .000***
regarded as one causative factor in developing Dentoalve U1/PPo 112.3 116.8 114.2 115.7 113.4 119.1 .000***
Class III malocclusion, this agrees with olar L1\MPo 96.17 87.17 86.83 81.75 86.75 89.81 .000***
relationshi
Battagel(2) and disagrees with Mouakeh(5) who p U1\L1o 128.1 128.8 127.2 134.1 125.4 128.3 .171(NS)

found no significant difference between class III

and class I group.
The (SN-MP) was significantly larger in groups
1, 2, 3 and 4 in Class III when compared with the
control group. This result agrees with Guyer et
al. (10), while in group 5 it was significantly
smaller (Namankani and Bukhary (25)).
The (PP-MP) was significantly larger in skeletal
class III groups (1, 2, 3 and 4) when compared
with the control group; this is in line with
Mouakeh (5).
Facial heights
The lower anterior facial height (LAFH) was
significantly larger in skeletal class III groups (1,
2, 3 and 4). This comes in line with Guyer et
al.(13); except for group 5 it was larger than that
in class I but statistically not significant and this
finding was mentioned by Namankani and
Bukhary (25).
There was no significant difference in the
posterior facial height (PFH) in group 1, 2 and 3
when compared with control group and this
agrees with Guyer et al.(10), while in group 4 it
was significantly smaller and this was found by
REFERENCES
1. McGill JS, McNamara JA JR. Treatment and post
treatment effects of rapid maxillary expansion and
facial mask therapy. Craniofacial growth series, the
Center of Human Growth and Development.
University of Michigan, An Arbor, Michigan 1999;
35:123-152.
2. Battagel JM. The etiological factors of Class III
malocclusion. Eur J Orthod 1993; 15 (5): 347-370.
3. Dietrich UC. Morphological variability of skeletal
class III relationships as revealed by cephalometric
analysis. Trans Eur Orthod Soc 1970; 46: 131-143.
4. Jacobson A, Evans WG, Preston CB, Sadowaski PL.
Mandibular prognathism. Am J Orthod 1974; 66:
140-171.
5. Mouakeh M. Cephalometric evaluation of
craniofacial pattern of Syrian children with Class III
malocclusion. Am J Orthod Dentofac Orthop 2001;
119: 640-649.
6. Moyers RE, Bookstein FL, Guire KE. The concept
of pattern in craniofacial growth. Am J Orthod.
1979; 76:136-48.
7. Freeman RS. Adjusting A-N-B angles to reflect the
effect of maxillary position. Angle Orthod 1981;
51:162-711.

Orthodontics, Pedodontics and Preventive Dentistry154

J Bagh College Dentistry Vol. 23(3), 2011
8. Baik CY, Ververidou M. A new approach of
assessing sagittal discrepancies: The Beta angle. Am
J Orthod Dentofacial Orthop 2004; 126:100–105.
9. Baik HS, Jee SGH, Lee KJ, Oh TK. Treatment
effects of Frankel functional regulator III in children
with Class III malocclusions. Am J Orthod
Dentofac. Orthop 2004; 125: 294-301.
10. Guyer EC, Ellis E, McNamara JA Jr, Behrents RG.
Components of Class III malocclusion in juvenile
and adolescents. Angle Orthod 1986; 56 (1): P 7-31.
11. Riedel RA. The relation of maxillary structures to
cranium in malocclusion and in normal occlusion.
Angle Orthod 1952; 22:142–145.
12. Al-Sahaf NH. Cross-sectional study of
cephalometric standards and associated growth
changes. A master thesis, Department of
Pedodontics, Orthodontics, and Preventive
Dentistry, University of Baghdad 1991.
13. Rakosi T. An atlas and manual cephalometric
radiography. London: Wolfe medical publications
Ltd. 1982, p. 7, 35-45, 66-67,113-116, 135.
14. Björk A. The face in profile: An anthropological x-
ray investigation on Swedish children and
conscripts. Svensk Tandl Tidskr, 1947.
15. Caufield PW. Tracing technique and identification
of landmarks. In Jacobson A (ed). Radiographic
cephalometry from basics to video imaging.
Chicago: Quintessence publishing Co 1995; p. 60.
16. Dibbets JM. Morphological associations between
the Angle classes. Eur J Orthod 1996; 18(2): 111-8.
17. Huang GJ, Justus R, Kennedy DB, Kokich VG.
Stability of anterior open bite treated with crib
therapy. Angle Orthod 1990; 60(1): 17-24.
Orthodontics, Pedodontics and Preventive Dentistry155
The characteristic features
18. ambrechts AH, Harris AM, Rossouw PE, Stander I.
Dimensional differences in the craniofacial
morphologies of groups with deep and shallow
mandibular antegonial notching. Angle Orthod
1996; 66(4): 265-72.
19. Dhopatkar A, Bhatia S, Rock P. An investigation
into the relationship between the cranial base angle
and malocclusion. Angle Orthod 2002; 72(5): 456-
63.
20. Donovan RW. Recent research for diagnosis. Am J
Orthod 1954; 40(8): 591-609.
21. Biggerstaff RH, Allen RC, Tuncay OC, Berkowitz J.
A vertical cephalometric analysis of the human
craniofacial complex. Am J Orthod 1977; 72(4):
397-405.
22. Sinclair PM, Little RM. Dentofacial maturation of
untreated normals. Am J Orthod 1985; 88(2): 146–
56.
23. Jones ML, Oliver RG. W&H Orthodontic Notes.
Oxford: Wright, 2000, p. 1-2, 24, 28-30, 62.
24. Horowitz SL, Converse JM, Gerstman GA.
Craniofacial relationship in mandibular
prognathism. Arch Oral Biol. 1969; 14: 121-131.
25. Namankani EA, Bukhary MT. Cephalometric
craniofacial characteristics of a sample of Saudi
female adults with Class III malocclusion. Saudi
Dent J 2005; 17(2):88-100.
26. Proffit WR, Fields HW, Sarver DM. Contemporary
orthodontics St Louis: Mosby Elsevier, 2007, p. 44-
46, 112-117, 302-303, 306-307.
27. Nojima K, Nagai H, Nishii Y, Sakamoto T,
Yamaguchi H. Morphological evaluation in skeletal
Class III malocclusion requiring maxillofacial
surgery using orthognathic surgical analysis. Bull
Tokyo Dent Coll 2002; 43: 163-171.
J Bagh College Dentistry Vol. 23(3), 2011 A cephalometric lips analysis

A cephalometric lips analysis and its relation to other

cephalometric measurements in Iraqi adult individuals
Yasir R. Al-Labban B.D.S., M.Sc.(1)

ABSTRACT
Background: The aim of this study was to evaluate and analyze the effect and behavior of the upper and lower lips
in class I Iraqi subjects.
Material and methods: True lateral cephalometric radiograph of the sample that comprises 60 females and 50 males
aged18-25 years and they possess class I skeletally and dentally. All the data have been analyzed by mean of
AutoCAD computer programs where 9 cephalometric angles have been analyzed.
Results: In males the mean value of lower lip inclination, the upper lip inclination, and interlabial angle have no
significant difference with that in females, so the mean values are 81.03, 84.2, and 158 respectively. The lower lip is
correlated with F. man., upper lip inclination, interlabial angle, interincisal angle, upper and lower incisor inclination.
The upper lip inclination is correlated with SGn. FH., F. man., interlabial angle, interincisal angle and lower lip
inclination. Interlabial angle is correlated with upper lip inclination, interincisal angle, lower lip inclination, and upper
central incisor inclination.
Kewords: upper and lower lip inclination, interlabial angle, soft tissue cephalometric. (J Bagh Coll Dentistry
2011;23(3): 156-159).

INTRODUCTION MATERIALS AND METHODS

Soft tissue covering of the face plays an
important role in facial esthetics, speech and other
functions (1). A harmonious soft tissue profile, an
important goal in orthodontics but sometime
difficult to achieve partly because the soft tissue
overlying the teeth and bones is highly variable in
its thickness (2), lips are flexible structures that
consist of muscle covered externally by skin and
internally by mucous membrane and submucosa.
Several muscles of expression are attached to the
muscle of the lips (3). Although both upper and
lower lips play a role in development of
malocclusion (4-6), the relationship between the
lips and the teeth is not clear (7-10). Several lines
have been done, worthy of mention is "Ricketts
E" line (11), which is influenced a great deal by the
growth of the nose. "Steiner's S" line (12)
eliminates half of the change in integumental
profile due to the growth of the nose."Holdway's
H" line (13) has the advantage of of removing the
influence of nasal growth in evaluation of lip
posture. Merrifield's "Z" angle (14) expresses the
full extent of lip protrusion in malocclusions. In
this study we are going to analyze the relationship
between the inclination of the upper lip, lower lip
and interlabial angle with other cephalometric
measurements in way to clarify the relation
between the above in static situation, so we can
conclude the norm for Iraqi individuals, which
would help the clinician in the diagnosis and
treatment plan.
(1) Assist. Lect, Department of Orthodontics, College of
Dentistry, University of Baghdad
This study is based on static situation, so out
of 350 college students (from college of dentistry.
Baghdad university), 110 subjects were selected
for the study. The sample comprised 60 females
and 50 males. All subjects in the present study are
aged 18-25 years and have class I skeletal and
dentally relationship according to ANB angle (2-
4), and first molar respectively (3-5), and have
competent lips and full set of dentition excluding
wisdom teeth. Also they have no history of any
kind of surgery in head and neck area. A lateral
cephalometric X-ray has been taken for the
sample, and the X-ray pictures are traced by help
of computer autocade program version 2007.
The variable and the landmarks used in
present study are as follows:
Point A, Point B, Orbitale, Porion, Nasion,
Pogonion, Gonion, Gnathion, Sella, Labrale
superius (Ls), Soft tissue pognion (Pog), Labrale
inferius (Li), Posterior columella point.
The angle used in the present study:
1. ANB angle; 2-4 degrees (4-6), as shown in
figure 1.
2. The angle between Frankfort plane and SGn
plane (15), as shown in figure1.
3. Mandibular plane angle (4-6,15); this angle
between Frankfort plane and mandibular
plane, as shown in figure 1.
4. Angulation of the lower lip; the line joining
the soft tissue Pog and labrale inferius (Li)
will form an angle with the mandibular
plane. This angle will be defined as the angle
of the lower lip plane, as shown in figure 1.
To secure reproducibility of this method 10
X-rays were randomly selected from the
sample. These 10 X-rays have been traced

Orthodontics, Pedodontics and Preventive Dentistry156

J Bagh College Dentistry Vol. 23(3), 2011 A cephalometric lips analysis

again after 2 weeks. To avoid memory bias 9. Inclination of the lower incisor. The line that
the independent T test has been calculated represent the long axis of lower incisor will
between the primary and secondary records intersect the mandibular plane, and the
of the X-rays, and insignificant difference posterior angle of this intersection is
has been concluded. regarded as the inclination of the lower
5. Angulation of the upper lip. The line drawn incisor, as shown in figure 2.
from PCm to labrale superius (Ls) was
termed the "PCm-Ls" line, as shown in RESULTS
figure 1. When this extends superiorly it will All the collected data have been subjected to
intersect the Frankfort horizontal plane. The descriptive statistics for both male and female
anteroinferior angle formed at this intersect groups. The independent sample T test revealed
was considered the relative inclination or that there is no significant difference between
angulation of the upper lip and was termed males and females (as shown in table 1) in the soft
the upper lip to Frankfort plane angle. tissue parameters, so we pooled both male and
6. Interlabial angle; this angle occurs between female groups together in one table during
the two lines determining the inclination of calculation of both descriptive and correlative
upper and lower lips, as shown in figure 2. statistics.
7. Interincisal angle; this angle occurs between
the two lines determining the inclination of
Table 1: Gender difference for the soft tissue
upper and lower incisors, as shown in figure
variables
2.
8. Inclination of upper incisors. The line that t – test
Variable Sig.
represents the long axis of upper central (d.f=108)
incisor will extend upward to intersect the Lower lip inclination -0.34 -0.73
SN plane. The posterior angle is regarded as LFH upper lip 1.9 0.061
the inclination of the upper central incisor, as Interlabial angle 1.46 0.15
shown in figure 2.
Table 2: Descriptive statistics for all parameters measured in this study for both male and
female groups
Variable N Min Max Mean SD
ANB 110 2 4 3.062 0.85
SGn. FH 110 48 66 57 3.74
F. Man 110 9 34 20.84 5.45
Lower Lip inclination 110 68 97 81.03 7.44
Upper lip. FH 110 56 110 84.2 11.05
Interlabial angle 110 76 180 158 16.26
Interincisal angle 110 96 149 121.39 11.32
Inclination of upper
110 86 134 109.6 9.02
central incisor
Inclination of the lower
110 85 121 99 7.74
central incisor

Table 3: Person coefficients of correlation for soft tissue parameters when compared with other
skeletal, dental, and soft tissue parameters
Variable Lower lip Upper lip Interlabial
r p- value r p-value r p-value
ANB 0.032 .801 -0.40 0.753 -.027 .829
Sgn FH -0.032 0.722 0.548** .000 0.004 .976
F man -.380** 0.002 0.335** .007 0.051 .688
Lower lip 1 -.344** .005 -.433** .000
LFH upper lip -.344** 0.005 1 0.503** .000
Interlabial angle -.433** 0.000 0.503** .000 1
Interincisal angle -.500** 0.000 0.325** .009 0.474** .000
Inclination of the
.333** 0.005 -.243 .053 -0.301 0.016
upper incisor
Inclination of the
.505** 0.000 -.206 .103 -0.173 0.171
lower incisor

Orthodontics, Pedodontics and Preventive Dentistry157

J Bagh College Dentistry Vol. 23(3), 2011
Figure 1: Five cephalometric
angular measurements: ANB
angle, SGn.F., F.Man.: Frankfort
mandibular plane, ULi: upper lip
inclination, LLi: lower lip
inclination.
Table 2 shows descriptive statistics for all
parameters measured in this study for both male
and female groups (total sample).
According to table 3 the behavior of lower lip
is inversely related to F.man, LFH, interlabial
angle, and interincisal angle while it's directly
related to upper and lower incisor inclination.
The behavior of upper lip is directly related with
SGn FH, Fman, interlabial angle, and interincisal
angle while it's inversely related to lower lip
inclination. The interlabial angle is directly related
to upper lip and interincisal angle while it's
inversely related to lower lip and upper central
incisor inclination.
DISCUSSION
Soft tissue changes have been shown to
accompany growth, as well as orthodontic
treatment (9,16-21). The direct effect of orthodontic
treatment on soft tissue profile is usually apparent.
Even more dramatic are the changes in the soft
tissue profile that may be induced by orthognathic
or plastic surgery. It is for these reasons that the
soft tissue profile must be carefully examined
before decision regarding orthodontic treatment
and/or orthognathic surgery can be made. In this
study we use 2 new terms, the first one is
inclination of lower lip so we can describe and
evaluate the behavior of lower lip.
Orthodontics, Pedodontics and Preventive Dentistry158
A cephalometric lips analysis
Figure 2: Four skeletal
measurements: Uii: upper incisor
inclination, iia interincisor angle, Lii
lowers incisor inclination, iLa
interlabial angle.
The second term is the interlabial angle; this
value will describe the behavior of both upper and
lower lips in combination with each other. In
other words it describes the relation between the
upper and lower lips when they act against each
other.
The finding of this study shows that the soft
tissue in both gender groups has the same
behavior. This finding will agree with that of
Fitzgerald et al. (15), but it disagrees with Singh (9)
who examined the soft chin thickness after
orthodontic treatment, he found that males
showed a greater increase in chin soft tissue
thickness than that of females. This disagreement
may be due to the fact that the Singh's (9) study
was on dynamic situations in addition to that
there's difference in the methodology of
evaluation of the soft tissues.
Regarding the gender difference the finding
of this study also disagrees with that of Oliver (8),
who based his study on teenage sample. This
disagreement may be due to difference in growth
pattern between male and female in teenage years.
The lower lip in this study shows significant
correlation with F.man, LFH, interincisal angle,
inclination of upper incisor, and inclination of
lower incisor. This finding was agreed with Rains
and Nanda (1) except for the relation with lower
incisor because they did not find significant
correlation between the behavior of lower incisor
J Bagh College Dentistry
and lower lip. This disagreement may be due to
difference in methodology and sex since they
based their study on females only.
The upper lip in this study shows significant
correlation with SGn.FH, Fman, lower lip and
interincisal angle. This finding disagrees with
Kasai (2) who found a relation between thickness
of upper lip with the position of lower incisor.
Also the thickness of upper lip associates with the
horizontal relationship between upper and lower
jaws. The significant correlations of upper lip in
this study disagree with the findings of Fitzgerald
et al. (15) who found negative correlation between
soft tissue and other hard tissue measurements in
well balanced profile. But the positive correlation
of upper lip in this study agrees with that of Rains
and Nanda (1) who found positive relation between
the upper lip behavior and lower lip behavior and
mandibular rotation.
Hershey (20) and Brustone (22) have proposed
that the perioral soft tissue may be self supporting
and that factors other than dental movement may
cause the wide variability of individual response.
This means that the response of upper lip varies
from one person to the other and this will explain
the wide range in findings of upper lip response.
The interlabial angle is formed by two lines,
one from the upper lip, and the other from the
lower lip and both are dependent or independent
to each other (this depends on lip competence).
The angular measurement described by these two
lines is resultant of interaction between upper and
lower lips, so the interlabial angle of a person may
be within normal range, small or large.
The measurement of interlabial angle alone
provides inadequate information as it does not
reveal which component is responsible for the
variability. It could be the upper lip, the lower lip
or both.
Therefore it is important to analyze each
component of this angle to assist in differential
diagnosis of normal from its variation.
Generally the positive relation between
interlabial angle and interincisal angle may
explain that both upper and lower lips when act
against each other can make an angle which will
reflect the interincisal angle, so it may act as an
analogue for interincisal angle.
REFERENCES
1. Rains MD, Nanda R. Soft tissue changes associated
with maxillary incisor retraction. Am J Orthod 1982;
81(6): 481-8.
2. Kasai K. Soft tissue adaptability to hard tissues in
facial profiles. Am J Orthod Dentofac Orthop1998;
133(6): 674-84.
3. Cunningham's. Manual of practical anatomy.
Volume 3. 14th ed. P.11- 111.
Orthodontics, Pedodontics and Preventive Dentistry159
Vol. 23(3), 2011 A cephalometric lips analysis
4. Bishara SE. Textbook of orthodontics. 1st ed.
Philadelphia: W.B. Saunders Company; 2001. p. 83-
98.
5. Proffit WR, Fields HW, Sarver DM. Contemporary
orthodontics. 4th ed. St. Louis: Mosby Elsevier;
2007. p. 94-142.
6. Graber TM, Vanarsdall RL Jr., Vig KWL.
Orthodontics: Current Principles and Techniques. 4th
ed. St. Louis: Elsevier Mosby; 2005.p 3-73.
7. Satravaha S, Schlegel DK. The significance of the
integumentary profile. Am J Orthod Dentofac
Orthop 1987; 92(5): 422-6.
8. Oliver BM. The influence of lip thickness and strain
on upper lip response to incisor retraction. Am J
Orthod 1982; 82(2): 141-9.
9. Singh RN. Changes in the soft tissue chin after
orthodontic treatment. Am J Orthod Dentofac
Orthop 1990; 98(1): 41-6.
10. Ramos AL, Sakima MT, Pinto AS, Bowman SJ.
Upper lip upper lip changes correlated to maxillary
incisor retraction- A metallic implant study. Angle
Orthod 2005; 75(4): 499-505.
11. Ricketts RM. Esthetics, environment, and law of lip
relation. Am J Orthod 1968; 54(4): 272-89.
12. Simon PW. Fundamental principles of a systemic
diagnosis of dental anomalies. Boston: The Stratford
Company; 1926. p. 64-76.
13. Holdaway RA. Changes in relationship of point A
and point B during orthodontic treatment. Am J
Orthod 1956; 42(3): 176-93.
14. Merrifield LL. The profile line as an aid in critically
evaluating facial esthetics. Am J Orthod 1966; 52
(11): 804-22.
15. Fitzgerald JP, Nanda RS, Currier GF. An evaluation
of the nasolabial angle and the relative inclinations
of the nose and upper lip. Am J Orthod Dentofac
Orthop 1992; 102(4): 328-34.
16. Waldo CM. Orthodontics research as a component
part of a balanced longitudinal study of 100 children.
Int J Orthod 1936; 22: 659-73.
17. Pelton JW, Elsasser WA. Studies of dentofacial
morphology. IV. profile changes among 6,829 white
individuals according to age and sex. Angle Orthod
1955; 25(4): 199-207.
18. Meng HP, Goorhuis J, Kapila S, Nanda RS. Growth
changes in the nasal profile from 7 to 18 years of
age. Am J Orthod Dentofac Orthop 1988; 94(4):
317-26.
19. Bloom LA. Perioral profile changes in orthodontic
treatment. Am J Orthod 1961; 47(5): 371-9.
20. Hershey HG. Incisor tooth retraction and subsequent
profile change in postadolescent female patients. Am
J Orthod 1972; 61(1): 45-54.
21. Mansour S, Burstone C, Legan H. An evaluation of
soft tissue changes resulting from LeFort I maxillary
surgery. Am J Orthod 1983; 84(1): 37-47.
22. Brustone CJ. Lip posture and its significance in
treatment planning, Am J Orthod1967; 53(4): 262-
84.
J Bagh College Dentistry Vol. 23(3), 2011 Soft-tissue cephalometric

Soft-tissue cephalometric norms for a sample of Iraqi

adults with class I normal occlusion in natural head
position
Zainab M. Kadhom, B.D.S., M.Sc.(1)
Mushriq F. Al-Janabi, B.D.S.,M.Sc.(2)

ABSTRACT
Background: The purposes of this study were to establish the cephalometric norms for Iraqi adults with normal
occlusion and well-balanced faces for both genders using Arnett et al. (1) analysis, to establish the mean values of
(the dentoskeletal factor, the soft tissues structures, the facial length, true vertical line (TVL) projection and the
harmony values measurements) and to verify the existence of gender difference
Materials & methods: 60 Iraqi adult subjects (30 males and 30 females) with an age ranged between 18-25 years
having normal occlusion and well-balanced face were chosen for this study. Each individual was subjected to
clinical examination and digital true lateral cephalometric X-ray in the natural head position which is mirror position in
which the patient looking straight into his eyes into the mirror mounted on the stand. The radiographs were analyzed
using AutoCAD program 2007 to measure the distances and angles used in the Soft Tissue Cephalometric Analysis.
Descriptive statistics was obtained for the measured variables for both genders and independent- samples t-test was
performed to evaluate the genders difference.
Results &conclusions: The results indicated that: females have high mean value of the angle between the maxillary
occlusal plane and TVL, increase in upper lip angle more than males. The males have thicker upper & lower lips,
more soft tissue chin thicknesses, higher mean value of the facial height, lower third of the face height, upper & lower
lip length, mandibular height, the projection of the maxillary & mandibular central incisor crown tip, soft tissue B & A,
nasal tip projection on the TVL and backward position of point Pog΄ and point B΄ than female.
Key words: Soft-tissue cephalometric analysis, class I normal occlusion, natural head position. (J Bagh Coll Dentistry
2011;23(3): 160-166).

INTRODUCTION
A commonly used craniofacial reference
plane is sella-nasion, SN, while this plane is
reliable and, by representing the anterior cranial
base, is biologically meaningful it has been
illustrated to have large inter-individual standard
deviations when related to vertical (VER). The
use of SN as a plane of reference has
questionable validity (2)
Another reference plane in widespread use is
Frankfort Horizontal, FH, as it may produce the
most acceptable estimation of HOR. The
Frankfort horizontal supposedly yields maximal
differences in the configuration of the cranium
between racial groups and smallest variability
within each group.(3)
Since intracranial landmarks are not stable
points in the cranium , their vertical relationship
to each other is therefore also subject to biologic
variation(e.g. sella to nasion, porion to orbitale)
(4,5)
. soft tissue facial measurement (11,12).
Natural head position (NHP) was introduced
into orthodontics in the late 1950 (3,4,6).
Broca (7) defined this head position as “when
man is standing and his visual axis is horizontal,
he is in the natural position”.
(1) MSc Student, orthodontic department, College of Dentistry,
Baghdad University
(2) Assistant professor, orthodontic department, College of
Dentistry, Baghdad University
A typical method of registering natural head
position is based on Solow and Tallgren’s work
in which subjects are asked to stand in
“orthoposition” and look into their own eyes in a
mirror after a series of neck flexion exercises (8).
Several lines and angles have been used to
evaluate soft tissue facial esthetics. The Riedel
plane and the Steiner aesthetic plane have been
used to describe the facial profile (9,10).
Arnett et al. (1) introduced a new soft tissue
cephalometric analysis tool. This analysis may be
used by the orthodontist and surgeon as an aid in
diagnosis and treatment planning.
The analysis is a radiographic instrument
that was developed directly from the philosophy
expressed in Arnett and Bergman “Facial keys to
orthodontic diagnosis and treatment planning,
Parts I and II” The novelty of this approach, as
with the “Facial Keys” articles, is an emphasis on
MATERIALS AND METHODS
The Sample
Out of 125 clinically and radiographically
examined subjects, only 60 subjects (30 females
and 30 males) fulfilled the inclusion criteria. The
sample included undergraduate students in the
College of Dentistry, University of Baghdad and
some students from nursing secondary in the
medical city. All of them were Iraqis Arabs with

Orthodontics, Pedodontics and Preventive Dentistry160

 J Bagh College Dentistry
an age ranged between 18-25 years. According to
Arnett et al. (1), Kalha et al. (13) , Uysal et al. (14),
Lalitha & Kumar (15) the following criteria were
used in the selection of the total sample:
1. Full permanent dentition regardless the third
molars.
2. No history of previous orthodontic treatment.
3. No history of facial trauma or craniofacial
disorder, such as cleft palate.
4. Class I occlusion with normal overjet and
overbite (2-4 mm).
5. Acceptable facial profile
6. Bilateral Class I buccal segments "molar and
canine" (16).
7. Skeletal Class I relationship determined
clinically by the two fingers method (17) and
radiographically by measuring the ANB angle
(18)
.
8. Minor or no spacing or crowding. (19).
The Equipment
1. X-Ray Unit.
2. Analyzing Equipments
a) Pentium IV portable computer.
b) Analyzing software (AutoCAD
2007).
The method
Each individual was seated on a dental chair
and asked information about name, age, origin,
history of facial trauma and previous orthodontic
treatment.
Clinical Examination
1. Assessment of the anteroposterior skeletal
relationship.
2. Assessment of the dental relationship
3. Measurement of the Overjet
4. Measurement of the Overbite.
Lateral Cephalometric Exposure (User's
Manual, 2004): In Natural Head Position
For the cephalometric profile recordings, the
subject stands relax in natural head position
which is mirror position which involved each
subject performing a series of neck-bending
exercises, by incline his head up and down in
increasingly smaller movements until they feel
comfortably positioned before Lateral
Cephalometric Exposure (8).(Fig.1).
The patient after that looking straight into
his eyes into mirror mounted on the stand 20 X
100 cm , 137 cm in front of the plane of the ear
rods (8).
A freely suspended chain was mounted in
front of the nasal rod of the cephalostate unite to
represent the True Vertical Line (TVL) which the
extra-cranial reference line of the cephalometric
radiographs (20) .(Fig. 1).
The body posture was controlled and the
subject was asked to assume a convenient head
Orthodontics, Pedodontics and Preventive Dentistry161
Vol. 23(3), 2011 Soft-tissue cephalometric
position while looking straight into his eyes in
the mirror. After adjustment of the cephalometer
the ear and nasal rods were inserted. Each subject
was then instructed to keep their teeth lightly
closed together (8).
Figure 1: Subject in the cephalostat in
natural head position
.
Cephalometric Analysis
Every lateral cephalometric radiograph was
analyzed by AutoCAD program to calculate the
linear and angular measurements
The TVL was positioned through subnasale and
was perpendicular to the natural horizontal head
position (21 ).
Firstly, the ANB angle was measured to
confirm that the subjects had Class I skeletal
relationship. Then, Arnett et al. (1) soft tissue
cephalometric analysis was used to diagnose the
subjects in five different but interrelated areas;
dentoskeletal factors, soft tissue components,
facial lengths, TVL projections, and harmony of
parts.
Cephalometric Landmarks (Figure 2):
1. Point G' (glabella).
2. Point N (Nasion).
3. Point Na’ (Nasion soft tissue).
4. Point NT (Nasal tip).
5. Point cm (Columella).
6. Point A’ (soft tissue A).
7. Point ULA (upper lip anterior).
8. Point ULI (Upper labial inferior).
9. Point LLS (Lower labial superioris).
10. Point LLA (lower lip anterior).
11. Point B’ (soft tissue B).
12. Point Pog’ (soft tissue pogonion).
13. Point Me’ (Menton soft tissue).
14. Point NTP (neck-throat point
15. Point Me (hard tissue menton
16. Point Pog (hard tissue pogonion).
17. Point Ap 1 (Apicale 1).
18. Point B (Supramentale).
19. Point lower lip inside (LL inside).
J Bagh College Dentistry Vol. 23(3), 2011 Soft-tissue cephalometric

20. Point Is (Incisor superius). C. Tissue thickness at Pogonion (Pog- Pog’).

21. Point upper lip inside (UL inside). d. Tissue thickness at Menton (Me- Me’). Upper
22. Point Ii or (Md1), (Incisor inferius):. lip angle
23. Point L6 (mandibular first molar). e. Naso-labial angle.
24. Point U6 (maxillary first molar).
25. Point Ap 1 (Apicale 1).
26. Point A (Subspinale).

Figure 4: Soft tissue structures

measurements.

Facial lengths measurements; include the

following measurements: ( Figure 5)
1. Facial height
2. Lower one-third height (Lower 1/3
height).
3. Upper lip length (ULL)
4. Lower lip length (LLL)
5. Inter-labial gap (ILG).
Figure 2: Cephalometric Landmarks
Maxillary incisor exposure (Mx 1 exposure).
According to Arnett et al. the following 6. Maxillary incisor exposure
measurements were obtained.. These 7. Maxillary height (Mx height)
measurements were grouped into: Mandibular height (Md height).
1. Dentoskeletal factors measurements;
include the following measurements (
Fig.3):
a. Upper incisor to maxillary
occlusal plane (Mx 1- Mx OP).
b. Lower incisor to mandibular
occlusal plane (Md 1- Md OP)
c. Maxillary occlusal plane (Mx
OP-TVL)..

Figure. 5.:Facial lengths measurements.

4. True vertical line (TVL) projection

measurements: These include the following
measurements (Figure 6.):
1. Glabella point projection.
2. Nasal tip point projection.
Figure 3: Dentoskeletal factor 3. Soft tissue A’ (point A’ projection).
measurements 4. Upper lip anterior (ULA) point
projection:
2. Soft tissue structures measurements; 5. Lower lip anterior (LLA) point
include the following measurements projection:
(Fig. 4.): 6. Soft tissue B’ (point B’ projection):
a. Tissue thickness at upper lip.
b. Tissue thickness at lower lip.

Orthodontics, Pedodontics and Preventive Dentistry162

J Bagh College Dentistry Vol. 23(3), 2011 Soft-tissue cephalometric

7. Soft tissue Pogonion’ (point Pog’

projection):
8. Soft tissue Subnasale (point Sn
projection.
9. Upper incisor tip measured to TVL
(Mx1 projection):
10. Lower incisor tip measured to TVL (Md1
projection).

b. Inter-jaw relations
(1) Sn-Pog’
(2) A’-B’
(3) ULA- LLA

Figure 6: True vertical line (TVL)

projection measurements

5. Harmony values measurements: In

c. Full facial harmony
which there are three types of measurements:
(1) Facial angle.
a. Intra-mandibular relations
(2)G'-A’.
(1) Md1-Pog’.
(3) G'-Pog’
(2)LLA-Pog’
Figure 7: (A), (B) and (C) Harmony values
(3) B’-Pog’
(4) Throat length (NTP to Pog’).
measurements.

RESULTS AND DISCUSSION

Arnett et al. (1) soft tissue cephalometric
analysis was used to diagnose the subjects in five
different but interrelated areas; dentoskeletal
factors, soft tissue components, facial lengths,
TVL projections, and harmony of parts.
All subjects were within normal range of
antero-posterior skeletal relationship (ANB angle
for male is: 3.05 ± 0.88, for female is : 3.07 ±
0.94 and total: 3.06 ± 0.91).
This study is the first study established in
Iraq as a cephalometric study by the Natural head
position method and Arnett et al. (1).
Soft tissue cephalometric analysis is the first
time used. The sexual differences are due to the
influence of the sex hormones on the facial
contour, which become very evident by
adolescence. The male bony structure is bolder
more prominent, with dominance of the forehead,
nose, chin and stronger contour of the mandible
(22)
. This comes with the general trend of males

Orthodontics, Pedodontics and Preventive Dentistry163

J Bagh College Dentistry Vol. 23(3), 2011
having greater measurements than females, this
is because males have longer growth period
This comes with the general trend of males
having greater measurements than females, this
is because males have longer growth period than
females (23-25).
From the results in table 1, for dentoskeletal
factors it has been shown that the mean value of
the angle between the maxillary occlusal plane
and TVL shows significant genders difference;
this comes in agreement with Kalha et al. (13) ,
although the results of the present study indicates
higher mean value in females than males, while
this disagrees with Arnett et al.(1), Uysal et al. (14)
and Lalitha and Kumar (13) who found non-
significant differences between both sexes.
All remaining parameters measured,
maxillary central incisor to occlusal plane and
mandibular central incisor to occlusal plane do
not show statistically significant differences
between males and females in our study and this
agrees with Arnett et al. (1) , Kalha et al. (13),
Uysal et al. (14) and Lalitha and Kumar (15).
Generally; the sample in this study in
comparison with other ethnic groups have slight
proclined upper central incisors and slight
retroclined lower central incisors this may be due
to difference in sample size or due to ethnic
factor.
The findings of the present study for the soft
tissue factors as it is show in the table 1,
indicated that there is significant differences
between the sexes; males have higher mean
values for upper lip thickness, lower-lip
thickness, pogonion-pogonion', and menton-
menton', this indicates that the males have thicker
upper and lower lips and soft tissue chin, this
comes in agreement with Arnett et al. (1), Kalha
et al. (13), Uysal et al. (14) and Lalitha and Kumar
(15)
. The mean value of naso-labial angle is
higher in males, due to more anterior position of
the point upper lip anterior, with a non-
significant difference between the sexes; this
comes in agreement with Arnett et al. (1) Uysal et
al. (14) and Lalitha and Kumar (15), while disagrees
with Kalha et al. (13) who found significant
difference between both sexes with a higher
mean value in females. The upper lip angle
shows significant higher mean value in females
than males due to more anterior position of the
point upper lip anterior in females; this comes in
accordance with Arnett et al. (1) while disagrees
with Kalha et al. (13), Uysal et al. (14) and Lalitha
and Kumar (15) who found a non-significant
genders difference.
In comparison with Arnett et al. (1), in this
study, the upper and lower lips and soft tissue
Orthodontics, Pedodontics and Preventive Dentistry164
Soft-tissue cephalometric
chin thicknesses are thinner than that of Arnett et
al. (1) and nearly the same to that of Kalha et al.
(13)
this may be attributed to the ethnic factor or
sample size .
From the results in table 1, for the facial
lengths it is clear that the mean values of facial
height, lower third of the face, upper lip length,
lower lip length and mandibular height are
greater significantly in males than in females;
this comes in agreement with Al-Taani (26) for
only the mean values of facial height, lower third
of the face, upper lip length which are larger in
male than female and Nasir (27) , Rasheed (28) for
only total facial hight all above comes in
agreement with Arnett et al. (1), Kalha et al. (13) ,
Uysal et al. (14). and Lalitha and Kumar (15) . On
the other hand, the inter-labial gap shows non-
significant genders difference; this comes in
accordance with Uysal et al. (14), while disagrees
with Arnett et al. (1), Kalha et al. (13) and Lalitha
and Kumar (14). These studies share in the same
results that the mean value of inter-labial gap is
higher in females than males, while the maxillary
central incisos exposure show significantly
difference in females than males this come in
agree with Arnett et al. (1) and Kalha et al. (13) and
disagree with Uysal et al. (14) who show very
highly significant difference in females than
males and Lalitha and Kumar (15) who show non
significant difference between both genders. In
comparism with other studies, all of the
parameters are lower than Arnett et al. (1), Kalha
et al. (13), Uysal et al. (14) and Lalitha and Kumar
(15)
; this may be attributed to the ethnic factor or
sample.
The findings of the present study for the
TVL projections as it is show in the table 1.The
maxillary height shows non-significant genders
difference; this comes in agreement with Kalha
et al. (13) and Lalitha and Kumar (15) and disagree
with Arnett et al. (1) and Uysal et al. (14) .
The males show significant higher mean
values regarding the projection of the maxillary
central incisor crown tip, and mandibular central
incisor crown tip on the TVL; this comes in
agreement with Arnett et al. (1), Kalha et al. (13),
Uysal et al. (14) and Lalitha and Kumar (15). The
distance between maxillary incisor crown tip and
TVL is more in males due to the increase of the
angle between the maxillary occlusal plane and
maxillary central incisor in males as previously
discussed in dentoskeletal factor.
The projection of upper and lower lip
anterior, glabella, soft tissue pogonion and
subnasale on the TVL show non-significant
genders difference, this agrees with Arnett et al.
(1)
and Uysal et al. (14) , while disagrees with
 J Bagh College Dentistry Vol. 23(3), 2011 Soft-tissue cephalometric

Kalha et al. (13) who found significant genders The males show significantly higher mean
differ. values in the distance between Md1-Pog', B'-Pog'
Generally; the sample in this study in and A'-B' than female. The last variable is higher
comparism with other ethnic groups have in male due to increase the distance of mean
retruded soft tissue pogonion point and soft value of the angle between the maxillary occlusal
tissue B point this may be attributed to the ethnic plane and TVL shows significant genders
factor or sample size . difference; this comes in agreement with Kalha
From the results in table 1 for the Harmony et al. (13), although the results of the present study
values it has been shown that the distance indicates higher mean value in females than
between LLA-Pog', NTP- Pog', Sn-Pog’, ULA- males, while this disagrees with Arnett et al.(1),
LLA, G'-A', G'- Pog' and facial angle show non- Uysal et al. (14) and Lalitha and Kumar (15) who
significant difference between both genders; this found non-significant differences between both
comes in agreement with Arnett et al. (1), Kalha sexes. Generally; the sample in this study in
et al. (13), Uysal et al. (14) and Lalitha and Kumar comparism with other ethnic groups has slightly
(15)
. Generally, the males have backward position protrusive lower lip.
of point B' in comparison with females.
Generally; the sample in this study in comparism REFERENCES
with other ethnic groups has slightly protrusive (1) Arnett GW, Jelic JS, Kim J, Cummings DR,
lower lip. Beress A, Worley CM Jr, Chung B, Bregman R. Soft
Table 1: The mean values, standard deviations and tissue cephalometric analysis: Diagnosis and treatment
genders difference for dentoskeletal factors, soft planning of dentofacial deformity. Am J Orthod Dentofac
tissue components, facial lengths, TVL Orthop 1999; 116(3): 139-253.
projections, and harmony of parts of the present (2) Broadbent BH. A new x-ray technique and its
application to orthodontia. Angle Orthod 1931; 1(2): 45-
study 66.
(3) Moorrees CFA, Kean MR. Natural head
Males Females Genders position, a basic consideration in the interpretation of
Variables
(N=20) (N=26) difference
cephalometric radiographs. Am J Phys Anthropol 1958;
Mean S.D Mean S.D Sig.
16(2): 213-34.
Mx 1- Mx OP 59.52 5.22 57.53 4.83 (NS)
Md 1- Md OP 61.08 5.94 62.47 4.97 (NS) (4) Bjerin R. A comparison between the Frankfort
Max OP- TVL 95.64 4.13 97.9 2.98 * horizontal and the sella turcica- nasion as reference
Upper lip thickness 13.57 1.5 12.29 1.08 *** planes in cephalometric analysis. Acta Odontol Scand
Lower lip thickness 14.26 1.38 12.18 0.94 *** 1957; 15(1):1-13.
Pog-Pog' 12.89 1.71 11.87 1.11 * (5) Thurow RC. Atlas of orthodontic principles. St
Me-Me' 9.09 1.34 7.43 1.25 *** Louis: CV Mosby, 1977.
Naso-labial angle 106.88 10.06 103.37 8.17 (NS) (6) Downs WB. Analysis of the dentofacial profile.
Upper lip angle 5.56 6.97 10.1 6.97 * Angle Orthod 1956; 26(4):191- 212.
Facial height 121.84 6.91 114.1 5.8 ***
(7) Broca M. Sur les projections de la tete, et sur
Lower 1/3 height 68.63 4.21 63.03 3.72 ***
un nouvean procede de cephalometrie, 1862 [Cited by:
Upper lip length 20.4 2.21 18.73 1.86 **
47.5 3.06 43.45 2.64 ***
Moorrees CF, Kean MR. Natural head position, a basic
Lower lip length
Inter-labial gap 0.73 0.23 0.9 0.64 (NS) consideration in the interpretation of cephalometric
Mx1 exposure 2.33 1.26 3.09 1.38 * radiographs. Am J Phys Anthropol 1958; 16(2): 213-34].
Mx height 22.73 2.46 21.65 2.3 (NS) (8) Solow B, Tallghen A. Natural head position in
Md height 49.57 3.24 44.38 2.82 *** standing subjects. Acta Odontol Scand 1971; 29(5): 591-
Glabella -9.94 5.41 -9.74 3.32 (NS) 607.
Nasal projection 16.2 2.36 14.9 1.37 * (9) Riedel, RA. An analysis of dentofacial
A' -0.61 1.53 0.22 1.26 * relationships, American J Orthod 1957: 43; 103–19.
B' -9.8 2.42 -7.6 2.43 *** (10) Steiner CC. Cephalometrics in clinical practice.
Pog' -6.62 2.89 -5.85 3.15 (NS)
Angle Orthod 1959; 29:8-29.
Sn 0 0 0 0 (NS)
Mx1 -11.7 3.22 -9.91 2.43 * (11) Arnett GW, Bergman RT. Facial keys to
Md1 -15.49 2.63 -12.53 2.3 *** orthodontic diagnosis and treatment planning. Part I. Am
ULA 1.33 1.7 2 1.68 (NS) J Orthod Dentofac Orthop 1993a; 103(4): 299-312.
LLA -1.07 2.37 -0.39 2.1 (NS) (12) Arnett GW, Bergman RT. Facial keys to
Md1-Pog' 8.94 2.99 6.8 3.32 * orthodontic diagnosis and treatment planning. Part II. Am
LLA –Pog' 5.59 2.8 5.38 2.74 (NS) J Orthod Dentofac Orthop 1993b; 103(5): 395-411.
B'-Pog' 3.28 1.66 1.84 1.76 ** (13) Kalha AS, Latif A, Govardhanc SN. Soft-tissue
NTP- Pog' 51.19 5.98 51.86 5.24 (NS) cephalometric norms in a South Indian ethnic population.
Sn-Pog’ 6.62 2.89 6 2.83 (NS) Am J Orthod Dentofac Orthop 2008; 133(6): 876-81.
A'-B' 9.24 1.94 7.85 2.06 *
ULA-LLA 2.39 1.34 2.54 1.61 (NS)
(14) Uysal T, Yagci A, Basciftci FA, Sisman Y.
Facial angle 164.16 5.21 163.73 4.45 (NS)
Standards of soft tissue Arnett analysis for surgical
G'-A' 9.53 5.22 9.88 3.72 (NS) planning in Turkish adults. Eur J Orthod 2009; 31(4):
G'- Pog' 4.99 5.61 4.56 4.96 (NS) 449-56.

Orthodontics, Pedodontics and Preventive Dentistry165

J Bagh College Dentistry Vol. 23(3), 2011
(15) Lalitha Ch, Kumar KGG. Assessment of Arnett
soft tissue cephalometric norms in Indian (Andhra)
population. The Orthod Cyber J 2010.
(16) Houston WJB. The analysis of errors in
orthodontic measurements. Am J Orthod 1983; 83(5):
382-90.
(17) Foster TD. A textbook of orthodontics. 2nd ed.
Oxford: Blackwell Scientific Publications; 1985.
(18) Riedel RA. The relation of maxillary structures
to cranium in malocclusion and in normal occlusion.
Angle Orthod 1952; 22(3):142-5.
(19) Ishikawa H, Nakamura S, Iwasaki H, Kitazawa
S, Tsukada H, Sato Y. Dentoalveolar compensation
related to variations in sagital jaw relationships. Angle
Orthod 1999; 69(6): 534-8.
(20) Proffit WR, Fields HW, Sarver DM.
Contemporary orthodontics. 4th ed. St. Louis: Mosby
Elsevier; 2007.
(21) Spradley FL, Jacobs JD, Crowe DP.
Assessment of the anteroposterior soft- tissue contour of
the lower facial third in the ideal young adult. Am J
Orthod 1981; 79(3): 316-25.
(22) Powell N, Humphreys, B. (1984): Proportions
of the aesthetic face. New York.
Orthodontics, Pedodontics and Preventive Dentistry166
Soft-tissue cephalometric
(23) Subtelny JD. A longitudinal study of soft tissue
facial structures and their profile characteristics, defined
in relation to underlying skeletal structures. Am J Orthod
1959; 45(7): 481-507.
(24) Trenouth MJ, Davies PHJ, Johnson JS. A
statistical comparison of three sets of normative data
from which to derive standards for craniofacial
measurements. Eur J Orthod 1985; 7(3): 193-200.
(25) Genecove JS, Sinclair PM, Dechow PC.
Development of the nose and soft tissue profile. Angel
Orthod 1990; 60(3):191-98.
(26) Al Ta΄aani MMA. Soft tissue profile analysis:
A cephalometric study of some Iraqi adults with normal
occlusion. A master thesis, Department of Orthodontics
Dentistry, University of Baghdad, 1996.
(27) Nasir DJ. Facial proportion and harmony of
young adults sample in Iraq: A clinical direct
measurement study. MSc thesis, College of dentistry,
University of Baghdad, 1996.
(28) Rasheed NA. Facial anthropometry, a
comparative study between Class I occlusion and Class II
division I malocclusion. . MSc thesis, College of
Dentistry, University of Baghdad, 2001.