Cases

Prosthetic Treatment of a Patient with Non-syndromic Oligodontia

Case Report A 21-year-old male patient admitted to our clinic due to malnutrition and aesthetic problems with loss of teeth. Patient wanted to complete the treatment quickly with low cost to stay for short time in TURKEY, after going back to abroad. We have learned with anamnesis, there is no systemic discomfort. He have lived with primary teeth for years and lost a lot of teeth before admitting to our clinic. As a result of extraoral examination did not found any abnormalities except for depressions in the middle facial area. Intraoral and radiological examinations showed that permanent dental germs were not developed except the upper central incisor teeth and the upper- lower 1st molar teeth. It has been learned that the lower persistent primary teeth and the lower right 1st molar tooth were extracted two months earlier. The patient’s teeth 16,11,21,26,36 had no periodontal problems or carries. Among the teeth numbered 11-21, diastema was observed. It was seen that there was a crest height and width at the adequate level in toothless areas. No problems were found in soft tissues and mucosa. It was detected that except the 3rd molar teeth, 22 permanent tooth germ hadn’t developed. Oligodontia diagnosis was made. No tests have been performed to assess whether an underlying genetic factor such as ectodermal dysplasia; but no physical abnormality were found in hair, nails, skin, eyes. The patient’s neuromotor development was appeared to be normal and there was no specific finding on physical examination to suggest any syndrome. Any abnormality were not found in congenital or subsequently in the ectodermal tissues and other systems except for the missing teeth. Dental treatment has been focused on because the criteria for the diagnosis of ectodermal dysplasia has not been found in our patient. Patient is told with all the details of implant treatment and necessity, but the patient is preferred to make overdenture prostheses because of economic reasons and time problems. Overdenture prosthesis has been preferred in order to meet the aesthetic expectations of our young patient, provide soft tissue support and correct the profile to use it for long term. The patient was informed about the treatment so that the treatment can be started. The first impressions were taken with alginate impression material (Cavex CA37, Haarlem, The Netherlands). On the models individual impression trays were prepared by using the self-curing acrylic resin (Imicryl, Konya, Turkey). Existing teeth were prepared in a knife edge style and after a week the temporary crowns were formed. Second impressions were taken from the patient using polyether impression material (Impregum Monophase, 3M ESPE, Seefeld, Germany) followed by edge shaping using individual tray and green stench. Afterwards, vertical dimension measurements were made by using Niswonger method with base and wax template. İmpressions and templates were sent to the technician after controlling the speaking interval with Silverman method. The alignment of the primer copings and casting substructures was prepared by the technician and was checked in the mouth. Function and phonation controls of the prosthesis were made after the arrangement of artificial teeth and the prosthesis was finished with the patient’s aesthetic expectations in mind. Regular oral hygiene is important. That’s why oral hygiene training has been given to this patient with so many follow-up. The patient’s oral hygiene training was supportive, both tooth and prosthesis maintenance and cleaning was explained. In addition, fluoride applications to the intaglio surface of the denture were advised. Six month oral hygiene return visits were scheduled to maintain and reinforce homecare performance as well as to assess the need to reline, rebase, or remake prosthesis. Discussion Many factors play a role in the etiology of congenital tooth deficiencies. Among these are genetic factors first. However, many factors such as intrauterine diseases, infectious diseases, drug use, environmental factors, radiotherapy application, trauma are mentioned. Oligodontia is most commonly associated with ectodermal dysplasia and Down syndrome. In syndrome-related diseases, physical abnormality may be seen in the appearance of the ear, eye, and skin organs of the patient. It is important to physically assess the patient in detail to distinguish whether oligodontia is “isolated” or “syndrome related. The clinical features of oligodontia include six or more missing teeth, lack of development of maxillary and mandibular alveolar bone height and reduced lower facial height. Diversity in teeth morphology may also observed along with problems in teeth development and eruption. The presence of diastemas, persistence of primary teeth, delayed eruption of teeth and alveolar bone hypotrophy all suggest a diagnosis of oligodontia. Panoramic radiography as a radiological diagnostic method is an useful method to diagnose congenital tooth deficiency and researchers recommend panoramic radiography to be used to help diagnosis for in patients with missing teeth. Patients suffering from oligodontia may have severe psychological, esthetic, and functional problems. Thus, early diagnosis and treatment of these patients are necessary. The prosthetic treatments include implants, removable prostheses, fixed dentures, and adhesive techniques. Bone augmentation and orthognathic surgery may be necessary when evaluating alveolar bone level and jaw associations, but these treatments are both difficult and long term. If the individual’s growth development is complete and healthy alveolar bone is present, the implant option also comes to the forefront. To read from the source, click on the link below : https://www.pulsus.com/scholarly-articles/prosthetic-treatment-of-a-patient-with-nonsyndromic-oligodontia-4419.html

Oral Medicine and Radiology Oral and Maxillofacial Surgery + 2 more

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Minisrew-assisted management midline deviation caused by impacted canine and replacement of 2 mandibular first molars by protraction of second molars and impacted third molars in Class II malocclusion

A young girl, 20-year-old, was transferred to Orthodontics department, the Affiliated Hospital of Stomatology, Chongqing Medical University, from general dentist after root canal treatment of her upper right first molar, with the chief complaint of tooth aesthetics such as maxillary dental midline deviation to the left, and clinical absence of the lower first molars and maxillary left canine. She was in good general health, but she was shy, silent and disliked to open her mouth or smile to show her tooth, because she felt unsatisfied with her anterior teeth aesthetics. Orthodontic documentation was requested before treatment. Frontal analysis showed her chin asymmetry to the right side due to unilateral and habitual mastication. The profile analysis showed a Class II aspect, with the protrusion of upper lips and the retrusion of mandibular. Intraoral examination, impaction of maxillary left canine, 3-mm maxillary midline deviation to the left, residual roots of mandibular left and right permanent first molar with 7 mm space in each side, anterior tipped mandibular second molars, extensive carious lesion in first and second molars (some of which have been treated), and server abrasion in maxillary right canine and premolars were found. Radiography, it was observed that maxillary left canine was impacted between maxillary left lateral incisor and left first premolar. The size and morphology of canine and impacted mandibular third molars were well as CBCT imagine shown, but the dilacerations of impacted maxillary left canine was detected in CBCT image. And the alveolar bone dimension around the residual roots was fine in CBCT evaluation. There wasn’t obvious morphological asymmetry of TMJ. No obvious lateral shift of the mandibular incisor and no limited or asymmetric movement could be found during the maximum open-close excise. Retreatment objectives The patient had maxillary midline deviation, impacted canine, residual roots of mandibular first molars and protrusion of maxillary incisors and upper lips, with a Class II division 1 malocclusion. Treatment objectives for this patient were to: (1)(managed the midline deviation by serial upper right first premolar extraction, correction of maxillary midline, traction of maxillary left impacted canine, and then extraction of upper left first premolar, Becker ACS (2) replaced space of the missing mandibular first molars by protraction of mandibular second molars bilaterally, Aktan et al. (3) improved soft tissue profile, D’Amico et al. (4) reduced increased over jet, Perillo et al. (5) maintained the mandibular incisors in the appropriate position, Xie et al. (6) modulated molars to a simulate Class II relationship and canines to a Class I relationship. Treatment alternatives The first alternative treatment plan was that extraction of maxillary right first premolar and the impacted left canine, which avoided the risk of traction failure of impacted canine after extraction of left first premolar. But extraction of canine could cause Bolton tooth-size discrepancy and occlusion problem. The second alternative treatment plant was extraction of mandibular third molar, distal movement of mandibular second molar and opening enough space for implants or placing fixed partial dentures for the missing mandibular first molar. But the implant would increase much more cost for the patient, and fixed partial denture might compromise the longevity of prepared adjacent tooth. The patient couldn’t accept this plan. The third option was that extraction of two maxillary premolar and the residual root of mandibular first molar and protracts the second molar to replace the first molar. After a carefully examination and evaluation of the alveolar dimension of edentulous sites by CBCT, it exhibited that the possibility to replace mandibular first molar by protraction of second molars bilaterally was quiet high. It also showed that obstruction of impacted canine would be the maxillary left lateral incisor and first premolar. While the dilacerations of canine could be found, the impacted canine traction should be successful after opening enough space. And after having a talk in detail with the patient and her parents, they choose this plan after a carefully discussion. Treatment progress The maxillary right first premolar and the residual roots of mandibular first molar were extracted followed by placement of fixed appliance Mini Uni- Twin Bracket (3M Unitek) 0.018” slot up to the second molars, which was considered as a low friction appliance. The treatment was initiated by 0.012- in nickel-titanium alloy(Ni-Ti) archwires and leveled and aligned from 0.014- in 0.016-in to 0.018-in Ni-Ti archwires. Then 0.018“Australian arch wire” was applied. For the maxillary, Open Coil Spring was set between the left lateral incisor and first premolar and laceback was used on the right side. For the mandibular, an omega loop was set in the mesial of second molar and a tip back bend were utilized bilaterally, to upright the second molars. After 12 months treatment, traction of impacted canine was successful and maxillary midline deviation was correct. After the maxillary midline deviation was treated, maxillary first premolar was extracted. And for the mandibular, ligation from the left second premolar to right second premolar was applied to reinforce the anchorage, and “lace back” was set between the anterior teeth and the second molar bilaterally to protract the second molar. After the second molar protracted forward, it offered enough space for the eruption and anterior movement of third molars. And after the maxillary left canine successfully entered the arch, the upper and lower arch were further leveled and aligned from 0.016 NiTi archwires followed by 0.018 NiTi, 0.016 × 0.022 NiTi, 0.018 × 0.025 NiTi and 0.018 × 0.025 stainless steel arch wires. While bilateral spaces in the maxillary is different, two 11 mm miniscrews were planted between the roots of maxillary second premolar and first molar bilaterally to retract the protrusion of upper incisors. Elastics chains were placed from the implant to the hook on the maxillary arch wire and from the second molar to the hook on mandibular arch wire, applying approximately 60 cN of force. The patient was recalled 4 weeks until the space was closed. The total active treatment period was 27 months. While there were no opposing teeth in the mandibular arch, the patient was referred for extraction of upper third molars. For both maxillary and mandibular, an invisible retainer for daytime and a Hawley retainer for nighttime were given. Results After the active treatment, the deviation of maxillary midline was corrected, the traction of impacted canine was successful, the protraction of mandibular second molar success, the third molar successfully erupted to the place of second molar, the protrusion of upper incisors was reduced and the lip and soft profile were improved. The patient had a Class II molar relationship and a Class I canine relationship. While we continued advising the patient to give up the unilateral and habitual mastication and chin asymmetry to the right side was improved, but the asymmetry still existed. Lateral cephalograms were taken at pretreatment and posttreatment. It showed that the skeletal pattern was maintained with no significant change of SNA, SNB, or ANB angles. The increased Interincisal angle (U1-L1), reduced U1- Maxillary Plane and overjet indicated that the maxillary incisors proclination was reduced, but the mandibular incisors were kept in an acceptable position as the IMPA and L1-MP(LADH) shown. And the Ricketts superimposition exhibited the improvement of upper and lower lips relationship as the Lower Lip to E-Plane and Upper Lip to E-Plane shown. To read from the source, click on the link below : https://www.pulsus.com/scholarly-articles/minisrewassisted-management-midline-deviation-caused-by-impacted-canine-and-replacement-of-2-mandibular-first-molars-by-protractio-4521.html

Oral Medicine and Radiology Orthodontics and Dentofacial Orthopaedics + 1 more

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Joint surgical and endodontic treatment of a huge keratocyst lesion (18 months follow up)

CASE REPORT A 32 years old male patient attended the oral and maxillofacial center complaining of pain, chin swelling, and intraoral fluid discharge. On clinical examination shows slight mobility of lower anterior teeth, swelling of the labial vestibule, tenderness, and fluctuation on palpation. Panoramic X-ray and C.T. Scan reveals an approximately 8 cm length and 2.5 cm height well defined radiolucent lesion extend from right to left molar regions including all the lower anterior teeth showing horizontally impacted lower left canine within the cystic lesion and with slight expansion and thinning of the cortical plate, aspiration shows keratin fluid content. ABSTRACT Odontogenic keratocyst is a locally aggressive developmental cyst that may appear in the mandibular third molar or canine region. It varies in size and as it widens it may interfere with the surrounding structures as teeth by compressing on their nerves and blood supply. Treatment is usually accomplished by enucleation, curettage and then bone grafting of the cystic space. Any non-vital tooth near the cyst space region may extrude toxic substances from the dead pulp space. The interaction between the extruding irritants from the root canal space and the host defense results in activation of numerous. inflammatory reactions which will not allow healing to the periapical region. Instrumenting and irrigating the root canal will remove all harmful microorganisms and leave a clean disinfected space. Obturating of the pulp space ensures blocking the space with inert or bioactive material that will enhance bone healing. Odontogenic keratocyst is a rare and benign but locally aggressive developmental cyst. It originates from the odontogenic epithelium (dental lamina) in the alveolus left from tooth development stages. They are mainly thought to arise from rests of Serres.Odontogenic keratocysts tend to grow in an anteroposterior direction within the medullary cavity of the bone without producing bone expansion. There is no specific effective treatment forthe treatment of odontogenic keratocysts. Most odontogenic keratocyst are treated by enucleation and curettage. Bone grafting may be used after the treatment of large odontogenic keratocyst to reduce the risk of pathological break.Odontogenic keratocyst may vary in size and may compress the adjacent teeth affecting their vitality and blood supply. Pulp necrosis is a clinical diagnostic category indicating the death of cells and tissues in the pulp chamber of a tooth with or without bacterial invasion and it is often the result of many cases of dental trauma. Debriding, irrigating and drying the necrotic root canal will ensure a favorable environment for obturation of the root canal space. Obturation is done by inert gutta-percha as a core material and sealer which is a film like creamy substance which may constitute bioactive material as mineral trioxide aggregate which promotes healing due to its high pH value. Under general anesthesia, surgical excision of the lesion through a three-sided intraoral incision extending from right 2nd molar to left 2nd molar of the lower jaw, their vertical incision on theintact bone and the horizontal incision including interdental papillae. Mucogingival flap was reflected subperiosteal with preservation of both mental nerves, thick lining cyst was completely excised with the removal of the impacted canine,peripheral osteotomy was done, and then a ribbon gauze soaked with Carnoy’s solution was applied to a bony defect for three minutes followed by copious irrigation with normal saline. Interrupted suturing was done, and removed one week later. The histopathological result was odontogenic keratocyst. After two weeks follow up shows good healing, then referring the patient to rootcanal specialist for root canal therapy of the lower anterior teeth. Endodontic protocol The patient attended the dental office referred to an oral maxillofacial surgeon. The patient operated in the mandibular anterior area. Cold vitality testing and electric pulp testing were done to the # 41, 42, 43, 44 and 31 teeth which were found to be non-vital.The patient was referred for endodontic treatment for these teeth and follow up of the healing of the case. PROCEDURE OF TREATMENT First appointment An access opening was performed to each tooth and remnants of the necrotic pulp were removed by a barbed broach. The pulp chamber and canal were filled with non-setting calcium hydroxide paste for 7 days and the access opening was closed with a ready-made temporary filling material. Second appointment The temporary filling material was removed by a high-speed handpiece and the calcium hydroxide paste was removed by a #15 K-file and then the pulp canal was washed with normal saline.After calculating the working length of each tooth by an apex locator,root canal instrumentation was done by the WaveOne Gold system (Dentsply Sirona) starting by the Small file (D0=0.2) then Primary file (D0=0.25) and if needed Medium file (D0=0.35). Vigorous irrigation with 2 ml NaOCl solution and with a side vented needle and Endoactivator sonic vibration (Dentsply Sirona) was done between each use of the files. Then 2 ml of EDTA solution was used to irrigate the canals and kept for 1 minute in the canals. After instrumentation, 5 ml of NaOCl solution with sonic vibration was done as the final irrigation. Finally, 5 ml of normal saline was used to irrigate the canals to remove any remnants of NaOCl. Complete dryness was done to the canals by sterile paper points. The pulp chamber and canal were filled with non-setting calcium hydroxide paste for 7 days and the access opening was closed with a readymade temporary filling material. Third appointment The temporary filling material was removed by a high-speed handpiece and the calcium hydroxide paste was removed by a #15 K-file and then the pulp canal was washed with normal saline.The complete dryness of the canals was done by sterile paper points.MTA based sealer was inserted into the canal by a #15 K-file to pant the root canal walls. Thermafil gutta-percha cone (Dentsply Sirona) of sizes resembling the size of the instrumentation files were used to obturate the root canals completely. Follow-up The patient was instructed to visit the office for a routine panoramic x-ray every 6 months. After 18 months, the lesion shows signs of radiolucency around and inside the lesion with no history of any signs and symptoms in the region during this period. Healing of the lesion is evident underway with non-surgical endodontics with no need for bone augmentation in the lesion space.After 18 months from endodontic treatment. Signs of radiographic radiolucent appearance around and inside the cyst space DISCUSSION Odontogenic keratocyst is commonly seen in the mandibular third molar and canine regions. If not removed they may spread antero posteriorly. It may affect the nerve and blood supply to the adjacent teeth rendering them non-vital. The contents of the necrotic pulp is harmful to the periapical region and will interfere in the healing of the surrounding structures. To read from the source, click on the link below : https://www.pulsus.com/scholarly-articles/joint-surgical-and-endodontic-treatment-of-a-huge-keratocyst-lesion-18-months-follow-up.pdf

Oral Medicine and Radiology Cyst and Tumors + 1 more

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Soft palate mass: An unusual case

Case report A 15 year old female reported to our Out Patient Department with a mass over the soft palate in the oral cavity for 2 months which gradually increased in size. It was not associated with pain, dysphagia, or oral bleeding. On examination of the oral cavity there was a bulge on the left side of the soft palate. On palpation the mass was about 2 × 2 cm in diameter with firm consistency, smooth surface margins, non-tender, and there was no breach in the mucosa. There was no loss of sensation over the swelling and the surrounding region. Palatal movements and gag reflex were intact. On panendoscopy there was no extension of the mass in the nasal cavity or the pharynx. Fine Needle Aspiration was increased number of vessels, monolayer of non-atypical endothelial cells with ill-defined cytoplasm suggestive of benign lesion. Computed Tomography scan suggested a well-defined cystic lesion in the soft palate with central brightly enhancing component within the lesion with homogenous enhancement during venous phase. Feature highly suggestive of vascular lesion. On Magnetic Resonance Imaging of oral cavity with Neck angiography a well-defined oval lesion of size 2.6 × 1.8cm in axial plain was seen in soft palate. The lesion was intensely hyperintense on T2 Weighted and Short TI Inversion Recovery (STIR) images and hypointense on T1 Weighted images. No abnormal feeder was seen to the mass on Magnetic Resonance angiography. Surgical excision of the lesion was done under general anesthesia. The mass was removed in total and wound was closed using absorbable suture (vicryl 4-0). The specimen was sent for pathology. Microscopic:Capsulated neoplasm composed of predominantly hypercellular areas. Spindle cells with wavy nuclei and eosinophilic cytoplasm seen arranged in whorled pattern with verrocay body formation. It showed occasional Antoni A and Antoni B areas. Few blood vessels seen scattered within the lesion with lymphocytes and hemosiderin laden macrophages. Discussion A case of Neurilemmoma of the head and neck region was first described by Bogdasanian and Stout.Verocay in 1908 described schwannoma as a benign encapsulated nerve sheath neoplasm composed of Schwann cells. Stout (1935) coined the term neurilemmoma believing that this tumor arises from cells of sheath of Schwann which may also develop in any part of the body. Schwannoma is a benign nerve sheath tumor arising from perineural Schwann cells which develop during the 4th week of gestation. Schwann cell is a type of glial cell of the peripheral nervous system that helps separate and insulate nerve cells. The tumor is frequently located in the head and neck region (25–48%) but only few (1%) are intraoral showing a predilection for the mobile portion of the tongue. Schwannoma of the palatal mucosa is extremely rare. Schwannomas are known to occur as solitary masses and they occur with a wide age range of first to eighth decades of life (average age 34 years) and with a definite female predilection. In some instances they are multiple and occur in association with neurofibromatosis type 2. To read from the source, click on the link below : https://www.sciencedirect.com/science/article/pii/S2468548818302327#fig1

Oral Medicine and Radiology

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