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Scientific Journal Published by the College of Dentistry University of Baghdad

Vol. 24 No. 2 2012 ISSN ISSN 1680-0087

A quarterly peer reviewed published scientific journal of the College of Dentistry, University of Baghdad.

Editor in chief: Prof. Dr. Nabil Abdulfatah Hatoor, M.Sc Vice editor in chief: Prof. Dr. Hussain Faisal Al-Huwaizi M.Sc., PhD
National Members Prof. Dr. Adel Farhan MSc Prof. Dr. Zainab Al-Dahan MSc Prof. Dr. Abbas Sabri M.Sc., PhD Prof. Dr.Wasan Hamdi M.Sc, PhD Assist. Prof. Dr. Lekaa Mahmood M.Sc Assist. Prof. Dr. Sabah Nema M.Sc., PhD Prof. Dr. Nidhal Hussain MSc Assist. Prof. Dr. Sahar Shaker MSc Assist. Prof. Dr. Ghassan Abdulhameed MSc International Members Prof. J. L. Gutmann D.D.S., Ph.D.(USA) Prof. Dr. M. Goldberg PhD (France)

Board of editorial consultants:


1- Prof. Dr. Majida Al-Hashimi MSc 2. Prof. Dr. Akram Al-Huwaizi MSc, PhD 3- Prof. Dr. Mohammad Al-Qaisi MSc 4- Prof. Dr. Raja Hadi MSc, PhD 5- Prof. Dr. Shatha Saleem MSc 6- Assist. Prof. Dr. Maha Shukri MSc 7- Assist. Prof. Dr. Abbas Fadhil PhD 8- Lecturer Dr. Jamal Abid MSc

Secretarial committee: 1- Lecturer Dr. Mohammad Nahidh 2- Lecturer Yassir AbdulKadum 3- Assist. Lecturer Ahmed Fadhil 4- Assist. Lecturer Ayad M. Al-Obaidi For consultation, please contact: Website: www.codental.uobaghdad.edu.iq E-mail: baghdad_dentistry@yahoo.com Telephone: (+9641)4169375 Fax: (+9641)4140738

Contents
i ii v
Editor and Editorial Board Contents Instructions for the Authors Restorative Dentistry

1 6 11 18 21 27

Effect of different metal surface treatments and thermocycling on shear bond strength of heat cure and light cure at Co/Cr and Ni/Cr interface. Ali M. Khursheed, Salah A. Mohammed. Comparison of certain mechanical properties including deflection fatigue resistance of Cobalt Chromium alloy & Nylon tooth colored clasping materials. Azhar Imran Majeed Al-Awady, Widad Abdul-Hadi AlNakkash A comparison of the retention of complete denture bases having different types of posterior palatal seal with different palatal forms. Mayada Qasim Abdul Khafoor An evaluation of the use different techniques of the thermoplasticized obturators on the coronal seal Mervat M. Al-Bakri, Hussain F. Al-Huwaizi An evaluation of apical microleakage in roots filled with thermoplastic synthetic polymer based root canal filling material (RealSeal 1 bonded obturation). Nadine J. Adbul-rada, Adel F. Ibraheem The effect of two types of disinfectant on shear bond strength, hardness, roughness of two types of soft liners. Rola W. Abdul-Razaq

Oral Diagnosis

32 39 47 51

Immunohistochemical detection to evaluate the biological role of Ti implants coated by a combination of fibronectin protein and hydroxyapitate (EPD) (in vivo study). Athraa Y.Al-Hijazi, Thair L-Al-Zubaydi, Eman Issa Mahdi Evaluation of 900 mhz mobile phone effects on palate and tooth germ development in mouse embryo (histological & immunohistochemical study). Faten H. Berto, Athraa Y. Al-Hijazi Chronological age estimation in adolescent and young adult subjects in relation to mandibular third molar development using digital panoramic image. Jaafar J. Attar, Jamal Ali AL-Taei Diagnosis of the angular hyperkeratotic lesions and the incidence of the etiologic factors. Jamal N. Ahmed

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56 62 66 70 75 80

Pre-implant computed tomography and insertion torque measurement in qualitative determination of trabecular bone density. Mahmood J. Hamzah, Jamal A. Al-Taei Evaluation of oral health status in a sample of autistic male children. Mayyadah H. Rashid, Raja H. AlJubouri Ovulation detection through salivary levels of sialic acid and glycosaminoglycans. Rand M. Al-khafagy, Sahar H. Al-Ani, Ali Y.Majid Temporomandibular disorders in association with stress among students of sixth grade preparatory and students of fifth year high schools. Toka T. Alnesary, Rafil H. Rasheed Histological evaluation of osseointegration around titanium implants in thyroidectomized rabbits (experimental study). Zaid Muwafaq Ali, Nada Mohammed Hasan Al-Ghaban Prevalence of pulp stone (Orthopantomographic-based). Zainab H. Al-Ghurabi, Areej A. Najm

Oral and Maxillofacial Surgery and Periodontology

85 88

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

Orthodontics, Pedodontic, and Preventive Dentistry

91 94 99 104 109 114 120

Effect of in-dental clinic bleaching agents on the releases of mineral ions from the enamel surfaces in relation to their times intervals. Afnan Al-Shimmer, Mohammad Al-Casey Physicochemical characteristic of unstimulated and stimulated saliva with different chewing gum stimulation. Alhan A. Qasim, Eman K. Chaloob. Dynamic lip to tooth relationship during speech, posed and spontaneous smile using digital videography. Ali S. Al-khafaji, Nagham M. Al-Mothaffar Dental caries in relation to oral infections and feeding types among children aged 2-5 years. Aseel Haidar M.J. Al-Assadi The staining effect of chlorhexidine mouthwash on non metallic brackets (An in vitro comparative study). Hayder J. Attar, Fakhri A. Ali Tooth attrition patterns in a group of Iraqi adults sample with different classes of malocclusion (A comparative study). Issam M. Abdullah, Ausama A. Al- Mulla Clinical significance of sella turcica morphologies and dimensions in relation to different skeletal patterns and skeletal maturity assessment. Kasim A. Obayis, Ali I. Al-Bustani

iii

127 137 144 150 155

Clinical performance comparison of a clear advantage series II durable retainer with different retainers' types. Mustafa M. Al-Khatieeb Stimulation of rabbit condyle growth by using pulsed therapeutic ultrasound (A radiographical and histological experimental study). Mustafa A.Qaisi, Nidhal H. Ghaib The relation between W angle and other methods used to assess the sagittal jaw relationship. Sara M. Al-Mashhadany A comparative study evaluating the microleakage of different types of restorative materials used in restoration of pulpotomized primary molars. Zainab A. Al-Dahan, Aseel I. Al- Attar, Huda E.A. AlRubaee Oral health status among a group of pregnancy and lactating women in relation to salivary constituents and physical properties (A comparative study). Zinah M. Taqi Issa, Sulafa K.El-Samarrai

iv

Instruction for the Authors


The Journal of the College of Dentistry accepts manuscripts that address all topics related to dentistry. Manuscripts should be prepared in the following manner: Typescript. Type the manuscript on A4 white paper, with page setup of 2.5 cm margins. Type the manuscript with English language font Times New Roman and the sizes are as follows: 1) Font size 18 and Bold for the title of the manuscript. 2) Font size 14, Bold and capital letters for the headings as ABSTARCT, INTRODUCTION, MATERIALS AND METHODS, RESULTS and REFERENCES. 3) Font size 12 Bold and italic for the names and addresses of the authors ex. Ahmed G. Husam 4) Font size 11 for the legends of the tables and figures. 5) Font size 10.5 for the text in the manuscript. 6) Font size 10 for the text inside the tables. 7) Font size 9 for the references at the end of the manuscript. Use single spacing throughout the manuscript and numbering of the pages should be in the lower right hand corner. Title of the manuscript: The title should be written with a capital letter for the first word as (Effect of the retention and stability.etc). Abstract and key words. The abstract should contain no more than 250 words. The abstract should be divided to the following categories: Background: (It contains a brief explanation about the problem for which the research was done as well as the aim of the study), Materials and methods:, Results:, and Conclusion:. Below the abstract, write 3-5 key words that refer as close as possible to the article. The abstract should be written by the font Century Gothic size 8. Text. The body of the manuscript should be divided into sections preceded by the appropriate major headings (INTRODUCTION, MATERIALS AND METHODS, RESULTS and REFERENCES) which are written in bold and capital. Minor headings should be typed in bold and subheadings should be not bold but underlined. References. References are placed in the text using the Vancouver system (Numbering system). Number references consecutively in the order in which they are first mentioned in the text. Identify references in the text, tables, and figures by Arabic numerals, and place them in parentheses within the sentence as superscription ex. (2). Use the style of the examples given below in listing the references at the end of the manuscript: Book 1. Hickey JC, Zarb GA, Bolender CL. Bouchers 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.

J Bagh College Dentistry

Vol. 24(2), 2012

Effect of different metal

Effect of different metal surface treatments and thermocycling on shear bond strength of heat cure and light cure at Co/Cr and Ni/Cr interface
Ali M. Khursheed , B.D.S. (1) Salah A. Mohammed, B.D.S., M.Sc. (2)

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

INTRODUCTION
The bond strength of the metal-resin interface of a prosthesis it is a key factor in determining the serviceability of that prosthesis (1). The bond between the metal surface of a prosthesis framework and the acrylic denture base that it supports has been a concern of clinician, if there is separation between these two materials, especially at the junction referred to as the external finishing line, the crack in that area become a haven for microorganisms and plaque accompanied by staining. So a stable bond between the metal and resin should exist to prevent microleakage and subsequent unfavorable results.
(1) MSc student, Department of Prosthetic Dentistry, College of Dentistry, Baghdad University (2) Assistant Professor, Prosthodontic department, College of Dentistry, Baghdad University

The actual bonding mechanism of metal to resin framework has had many recent modifications with three basic systems used (1-3). (1) Mechanical Retention System; this system is subdivided into; (a) Macromechanical retention system retention which involves different techniques (retentive element technique, pitting corrosion technique); (b) Micromechanical retention system which involves (air particle abrasion, electrolytic etching and chemical etching. (2) Chemical retention system which is applied through (oxidation technique, tin plating and adhesive agents). (3) Mechanical/Chemical retention system this system was achieved by a combination of mechanical and chemical retention techniques ,the most widely used technique in this system is silicoating technique which produced several systems other than conventional silicoater
1

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Effect of different metal

including (Silicoater MDSystem, Rocatec System and Kevloc System (4) .This study was designed to evaluate the effect of different types of metal surface treatments on shear bond strength of two types of acrylic resins (heat cure and light cure). Metal Primer II (GC Corp, Tokyo, Japan), which contains a special functional monomer methacryloyloxyalkyl thiophosphoric methacrylate (MEPS) which promotes bonding by penetrating the metal alloy due to presence of phosphate group that presents chemical bonding with the surface layer of oxide of chrome formed in the surface of Co/Cr, which can reliable to promote better union of with metal, in addition, Metal Primer II forming co-polymerizing with the resin to produce both a mechanical and chemical bond to metal surface (5-6) .

MATERIALS AND METHODS


120 samples were prepared by using metal mold constructed and designed to reproduce wax patterns with modeling sheet wax( Dentaurum, Germany ) which was a rectangular plate (30 mm X 30 mm X 2 mm) that incorporated a central area (8mm X 12mm). On the upper surface there is a metal handle which facilitate holding of the mold during wax patterns procedure. The wax pattern was sprued ,investd (Rema R Exakt, Dentaurum, Germany) and cast in CobaltChromium alloys (Remanium R Gfh, Dentaurum, Germany),and Nickle-Chromium alloys (CB BLANDO 72 ,Hatakeyama Dental MFG, Japan ).Each sample was cleansed from investment material and electropolished for 12 minutes to produces samples with a brilliant finished surface

type of surface treatment that will be performed. A group of 40 samples (A1,B1,C1,D1) receive no surface treatment and no thermocycling for controlling purposes .Another 40 samples (A2, B2,C2, D2) were subjected to metal primer II pretreatment and thermocycling ,the last 40 samples were subjected to a combination of air abrasion and Metal Primer pretreatment with thermocycling (A3, B3 ,C3,D3). Application of acrylic resin to grouping samples The metal samples receiving HCR, a special mold was made from brass to reproduce the wax pattern which were rectangular block (12mm length ,8mm width ,and 6 mm height ) ,the wax was melted in a small stainless steel container by using electrical thermo- mat at 10 degree and poured inside metal mould ,then these block were sealed in the central area of metal sample ( 8mm X 12mm) .The conventional flasking procedure for acrylic denture construction was followed , for the second subgroups; after wax elimination and before packing of acrylic resin, 2-3 drops of Metal Primer II were dispensed into a dappen dish or similar container, and then applied as a thin layer to the central mesh area of metal sample. The acrylic resin was applied to the treated surface after 5 seconds according to manufacturers instructions.

Figure 2: Application of metal primer to metal sample which received heat cure acrylic resin
For third subgroups, the sample was treated first with air abrasion by using laboratory air abrasive blaster with 250 m aluminum oxide at air pressure of 4 to 6 bar for 1 minute, the samples were held with a specially designed fixture for standardization of the distance between the metal surface and the nozzle of the device (20 mm),all the metal samples that receive HCR were trimmed ,smoothed and polished. The metal samples receiving VLCR were treated with a chemical bonding agent that was applied by brush to the central area of the metal samples which are now ready for light cure resin application, it was directly applied resin to metal sample .No flasking procedure is needed.
2

Figure 1: Finished and electropolished metal samples


This study consisted of 120 samples prepared by divided into two groups according to the type of metal used .Group {A}&{C} refers to the metal samples that will receive heat-cure clear acrylic resin(HCR), while group {B}&{D} refers to metal samples that will receive light cure acrylic resin(VLCR). Samples of each group were then furtherly subdivided into three groups; each one consists of 10 metal samples, according to the
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Effect of different metal

Figure 3: Finished Metal Samples with Heat Cure Acrylic Resin (Group A ,C).

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

Figure 4: Application of Metal Primer II for Light Cure Acrylic resin


For the light cure acrylic resin the sheets of acrylic are ready to apply directly without any preparation or mixing like heat cure acrylic resin. For the curing of light cured specimens a special glass mould (12cm 12cm) contains the same dimensions and angulations of the rectangular block was designed The glass mould contains rectangular block and has two glass covers upper and lower in order to permit for two sided curing in the light curing device and perforated with four openings for the tightens of the two glass covers with metals bolts in order to provide firm pressure during curing, the metal bolts were placed in their position and then they were tightened by using wrench and tightened for only one click for standardization. After adaptation of light cure acrylic, then cured with light cure unit (Yeti-Dental, Germany) at 400 to 500 nm wave length for 10 minutes {as manufacturer instructions} and After polymerization, the samples were trimmed, smoothened and then polished.

Figure 6: The vertical load applied using stainless steel chisel shaped rod

RESULTS
The result of this study were collected and analyzed statistically. Mean, standard deviation, minimum and maximum values of shear bond strength in Mpa of all groups are presented in tables 1&2. Source of differences was investigated by further complement analysis of data (Least Significant Difference, LSD test) to examine the difference between difference pairs of the three groups as shown in Tables 3&4 , where group {A}&{C} refers to the metal samples that will receive heatcure clear acrylic resin, while group {B}&{D} refers to metal samples that will receive light cure acrylic resin. Samples of each group were then furtherly subdivided into three groups; each one consists of 10 metal samples, according to the type of surface treatment that will be performed. A group of 40 samples (A1,B1,C1,D1) receive no surface treatment and no thermocycling for controlling purposes .Another 40 samples (A2, B2,C2, D2) were subjected to metal primer II pretreatment and thermocycling ,the last 40 samples were subjected to a combination of air

Figure 5: Light cure Acrylic Resin (Group B, D) after Curing


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Effect of different metal

abrasion and Metal Primer pretreatment with thermocycling (A3, B3 ,C3,D3).

DISCUSSION
In the present study, shear bond strength of metalresin interface was evaluated , the specimen were held at 90 degree so that the direction of the force applied to the specimen was vertical. All of the specimen were tested with instron machine using stainless steel chisel shaped road at a constant crosshead speed of 5 mm min until failure of the bond occurredAll the specimens were prepared using standard laboratory methods commonly used for clinical prosthesis and the specimen groups that received no more than the conventional macromechanical retention system which represented by the large mesh and without thermocycling, was prepared as control group Many studies showed that there is an increase in the bond strength of the metal resin interfaces when the alloy is treated with various metal surface treatments Effect of Different metal Surface Treatments on SBS for Heat cure Acrylic Resin-Metal interface This study shows that the SBS mean values of metal primed and thermocycled of the Heat Cure Resin-metal interface less than subgroup that were not subjected to surface treatment and without thermocycling ,this results may be explained by the reaction with water, such as swelling of the acrylic resin due to water sorption, stresses resulting from the difference in the coefficient of thermal expansion, thermocycling speed up the diffusion of water in between resin and metal, Metal Primer II (chemical bonding agent) increased SBS between the metal and both two types of acrylic resins (heat and VLC). Metal Primer II (GC Corp, Tokyo, Japan), which contains a special functional monomer methacryloyloxyalkyl thiophosphoric methacrylate (MEPS) which promotes bonding by penetrating the metal alloy due to presence of phosphate group. This group presents chemical bonding with the surface layer of chrome oxide formed in the surface of Co/Cr, which is reliable to promote better union with metal, in addition, Metal Primer II lead to co-polymerization with the resin to produce both a mechanical and chemical bond to metal surface ,also this study show that the SBS mean values of metal primed ,air abraded and thermocycled samples of the Heat Cure Resin-metal interface less than subgroup that were not subjected to surface treatment and without thermocycling yet it was higher than metal primed and thermocycled
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samples of Heat cure Acrylic Resin-metal interface, because the effect of air abrasion raised mean bond strength values than that of only metal primed subgroup , the effect of the Air Abrasion on the bond of metal to resin could be explained that when the particles of Air Abrasion hit the metal surface and their kinetic energy is transformed to thermal energy, which may reach the melting point of metal alloy. The melting of the metal alloy is limited to 1 or 2 m from the surface. Effect of Different metal Surface Treatments on SBS for Light cure Acrylic Resin-Metal interface This study show that the SBS mean values of metal primed and thermocycled of the Light Cure Resin-Metal interface less than subgroup that were not subjected to surface treatment and without thermocycling Since thermocycling cause hydration of the specimens, so this will leads to decreasing the shear bond strength after thermocycling, Also, the water sorption of VLC were found to be greater than that of the other types of acrylic resin, so the material absorbed water and this had a damaging effect on the bonding. This study also show that the SBS mean values of metal primed ,air abraded and thermocycled samples of the Light Cure Resin-metal interface less than subgroup that were not subjected to surface treatment and without thermocycling ,yet it was higher than metal primed and thermocycled samples of Heat cure Acrylic Resin- metal interface subgroup, because the effect of air abrasion raised mean bond strength values than that of only metal primed subgroup,this might be due to the result of the combination of micromechanical retention that was achieved by the Air Abrasion and chemical retention that was achieved by the Metal Primer II which provided adhesive bridges between the metal surface and resins (heat cure or VLC resins), the effect of the air abrasion on the bond of metal to composite resin could be explained by increasing the surface area of alloy surface ,expanding the energy of the alloy and also highest the activity of the surface of alloy. The effect of air abrasion particle results in deposition of molecular coating of alumina and silica on the metal surface. Air Abrasion with aluminum oxide on the surface of cobalt-chromium alloy favors the bonding between the chrome oxide and resin. Moreover, Air Abrasion promotes formation of surface irregularities on the metal, achieving micromechanical bonding when resin flows through these irregularities.

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Effect of different metal

REFERENCES
1. Sharp B, Morton D, Clark A.E. Effectiveness of metal surface treatments in controlling microleakage of the acrylic resin-metal framework interface. J Prosthet Dent 2000; 84:617-622. 2. Ohkubo C, Watanabe I., Hosoi T, Okabe T. Shear bond strengths of polymethyl methacrylate to cast titanium and cobalt-chromium frameworks using five metal primers. J Prosthet Dent 2000; 83:50-7 3. Kim JY, Pfeiffer P, Niedermeier W. Effect of laboratory procedures and thermocycling on the shear bond strength of resin-metal bonding systems. J Prosthet Dent 2003; 90:184-9.

4. Pesun S, Mazurat R. Bond strength of acrylic resin to cobalt-chromium alloy treated with the silicoater MD and Kevloc systems. J Can Dent Assoc 1998; 64:798802. 5. Freitas AP, Francisconi PAS. Effect of a metal primer on the bond strength of the resin-metal interface. J Appl Oral Sci 2004; 12(2):113-6. 6. Silveria de Araujo C, Incerti Da Silva T, Ogliari FA, Meireles SS, Piva E, Demarco FF, Microlekage of seven adhesive system in enamel and dentine. J Contemp Dent Pract 2006; 5(7):26-33.

Table 1: Mean Shear bond strength (SBS) of subgroups samples at Heat Cure Resin-metal interface (Group A&C)
Statistical Analysis Mean SD Min Max A1 5.9 1.05 4.6 7.62 A2 4.7 0.9 3.4 6.1 A3 5.1 0.8 3.9 6.3 C1 4.8 1.1 2.4 6.4 C2 4.1 1.3 2.4 6.1 C3 4.1 1.1 2.22 6.17

Table 2: Mean Shear bond strength (SBS) of subgroups samples at Light Cure Resin-metal interface(Group B&D)
Statistical Analysis Mean SD Min Max B1 4.6 0.9 2.8 6.4 B2 3.3 0.9 2 4.8 B3 3.5 1.3 2 6.4 D1 3.8 0.7 2.6 5.1 D2 2.7 0.9 1.6 4.6 D3 3.1 0.6 2.1 4.1

Table 3: Least significant difference for the Subgroups samples of Heat Cure resin-metal interface (Group A&C).
(I) (J) Group Group A1&A2 A1&A3 A2&A3 C1&C2 C1&C3 C2&C3 (I-J) 1.148 .7244 -.424 .65100 .6130 -.0380 P value .014 .110 .342 .247 .275 .945 Significance S NS NS NS NS NS

Table 4: Least significant difference for the Subgroups samples of Light Cure resin-metal (Group B&D).
(I) (J) Group Group B1&B2 B1&B3 B2&B3 D1&D2 D1&D3 D2&D3 (I-J) 1.33 1.13 -.19 1.0 .76 -.31 P value .01 .03 . 69 .00 .03 .36 Significance S S NS HS S NS

Restorative Dentistry

J Bagh College Dentistry

Vol. 24(2), 2012

Comparison of certain

Comparison of certain mechanical properties including deflection fatigue resistance of Cobalt Chromium alloy & Nylon tooth colored clasping materials
Azhar I.M. Al-Awady, B.D.S., H.D.D., M.Sc.(1) Widad Abdul-Hadi Al-Nakkash, B.D.S., H.D.D., M.Sc. (2)

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

INTRODUCTION
The removable partial denture must have retention to resist reasonable dislodging forces. Primary retention of a removable partial denture is accomplished mechanically by placing retention elements on the abutment teeth (1). A direct retainer is any unit of a removable dental prosthesis that engages an abutment tooth in such a manner as to resist displacement of the prosthesis away from basal seat tissue. This may be accomplished by frictional means, by engaging a depression in the abutment tooth, or by engaging a tooth undercut lying cervically to its height of contour (2). There are two basic types of direct retainers. One is the intracoronal retainer, which is cast or attached totally within the restored natural contours of an abutment tooth. The other type of a retainer is the extra coronal retainer, which uses mechanical resistance to displacement from components placed on or attached to the external surface of an abutment tooth (1). The extra coronal or clasp direct retainer is used more frequently than attachment (3). The problems of clasp arm include poor aesthetics and fracture of clasp arm (1). The application of nylon like materials in the fabrication of dental appliances has been seen as an advance in dental materials.
(1) Head of the prosthetic department of specialized center of dentistry, Thi Qar, An-Nasirya. (2) Professor, department of Prosthetic dentistry, college of dentistry university of Baghdad.

These materials generally replace the metal, and pink acrylic denture used to build the framework for standard removable partial dentures (4). 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 (5). Flexite Company developed and patented the firs tooth color clasps known. This product made of a nylon material (6). Fatigue testing which is subjecting a test sample to rapid cycling at a given stress until failure occurs is considered one of the basic testing procedures used to provide data for metals and alloys comparison (7), in addition fatigue is responsible for 90% of all service failure (8). The retentive clasp arms are the parts of removable partial denture most frequently damaged (9,10) since clasps in clinical use are subjected to cyclic bending during insertion, removal of partial dentures and also during mastication (7).

MATERIALS AND MTHODS


Tensile strength test: an analog of the specific shape and dimensions of the sample required (according EN.ISO. 527-2: 1993) was made from galvanized steel and used for molding a silicon mold to produce standardized wax patterns from which samples were made. Thirty samples were dedicated for this test. Ten samples of Flexite supreme; group A (Flexite USA) & ten of
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commercial nylon; group B (made in China) were injected using a thermoplastic injection system (KCX-09A, China). The same wax patterns were used for casting ten Co-Cr samples. All Cobalt Chromium samples were checked for unforeseen impurities that may have been hidden below the outside surface (figure 1). The samples were seated individually on the X-Ray machine (Diamax Digivision, Planmeca, Finland) at a distance of 10 cm. between the sample to be tested and the radiographic cone was achieved using the film holder. The X-Ray machine was set to 70 KV, 10 MA and the exposure time was 0.6 seconds (11-13). All samples that are proven to have air bubbles or cracks in the testing area (the area of constriction & not the handles) were discarded.

Deflection fatigue resistance test: the same procedures for the production of samples were followed to produce the 120 samples required for this test (40 samples of each material). The shape and dimensions of the samples were prepared according to (ASTM E647/1988). The test was

Figure 2: A polymer specimen clamped by the jaws of the testing machine after the test is over by failure in tension.

Figure 1: Cropped picture showing a void in the testing area of the sample. Samples showing a defect under X-Ray were discarded. The nylon samples were tested using a tensile testing machine with jaws designed to grip polymer samples (figure 2). The metal samples were tested with a tensile testing machine with jaws designed to grip metal samples (figure 3). The test was completed by loading the samples till failure in tension with a head speed of 20mm. per sec. The values of the tensile strength were calculated for each test specimen as the force at failure divided by the cross sectional area according to the following formula: Tensile strength = F (N.) / A (mm.)
(14)

F: Force at fracture A: Original cross-sectional area (ASTM specifications D-638 M, 1986). The modulus of elasticity (E), were determined using the method of comparing two different points on the stress strain curve and then applying the following formula:

E= 2- 1/ 2- 1 1: stress on the first point 2: stress on the second point 1: strain on the first point 2: strain on the second point
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(14)

Figure 3: A metal specimen clamped by the jaws of the testing machine after the test is over by failure in tension. carried out by screwing the grip of the testing machine (HSM20, HI-TECH EDUCATION, England). The deflection values (0.25mm.;0.5mm.; 1mm.; & 2.1 mm.) were obtained from the monogram provided with the manual of the machine. In a dental appliance, stress reversal is unlikely to occur & the structure will be stressed in one direction & allowed to return to zero in each cycle (15) & (16) & in this study, this stress cycle was used. Each sample was marked in the center of its length. The deflections of 0.25mm, 0.5mm, 1mm. and 2.1mm were measured at this point for all the samples by a dial gauge with an extended spindle whose tip was applied to the central point in the upper surface of the sample (13) & (17). After a sample had been setup in the testing machine, the sample was fatigued until fracture or permanent deformation occurred (figure 4 & 5).

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Figure 4: Samples showing cracks in the area to be tested. Figure7: Stress strain curve of test group A (Flexite supreme) samples under tension.

Figure 5: Propagation of a crack leads to an eventual sample fracture.

RESULTS
Stress strain curves of the materials were plotted demonstrating the behavior of the tested material in tension and as follows: 1. Co-Cr alloy is stiff, brittle but strong (figure 6).

Figure 8: Stress strain curve of test group B (commercial Nylon) under tension.
For the ultimate tensile strength, yield strength and modulus of elasticity Co-Cr had the highest mean values, respectively: 614.14 MPa; 337.84MPa &120.794MPa. While for the elongation of breakage it had the lowest mean value of 9.83 %. For the ultimate tensile strength, yield strength and modulus of elasticity Flexite supreme had the following mean values respectively: 152.2MPa; 148.17MPa & 10.4778 MPa. While for the elongation at breakage it had the highest mean value of 198%. For the ultimate tensile strength, yield strength and modulus of elasticity the commercial nylon had the lowest mean values, respectively: 45.81MPa; 34.73MPa & 5.6153MPa. While for the elongation at breakage it had the lowest mean value of 173.64 %. Multiple group comparisons of mechanical properties: By conducting Fisher's least significant difference test (LSD), to obtain an understanding of the multiple statistical comparisons among groups. The results were found to be as follows: When comparing the Co-Cr with Flexite supreme test group for yield strength, ultimate strength, modulus of elasticity and elongation at breakage the results revealed a statistically high significance.

Stress MPa

Strain %

Fig. 6: Stress strain curve of the mean value of (Co-Cr) samples under tension. 2. Flexile supreme: flexible, ductile and strong (fig. 7).
3. Commercial nylon: stiff, ductile and weak (fig. 8).

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Comparing Co-Cr with commercial Nylon test groups for yield strength, ultimate strength, modulus of elasticity and elongation at breakage the results revealed a statistically high significance.

elasticity the results revealed a statistically highly significant, and as shows in the (table 1).

DISCUSSION
1. Mechanical properties: The Co-Cr group registered E & yield strength, which are a poor feature concerning clasp design (18). While the Flexite supreme registering yield strength and modulus of elasticity that are lower than those of Co-Cr and higher than that of the commercial nylon , they might represent the ultimate choice of a material that can flex out of deeper undercut ;thus minimizing the amount of tooth preparations and the otherwise un necessary loss of healthy tooth structure, enhancing retention of a removable partial denture & minimizing the amount of stress excreted on the abutments .The amount of stress required to produce the necessary retention in Flexite Supreme Nylon clasps is delivered through the increase of bulk of the clasp, noting that such an increase wouldn't overload the prosthesis weight; hence Nylon low density compared to most base metal alloys; nor affect the aesthetics of the patient; hence the tooth colored or gingiva colored clasp. The commercial nylon (made in china) proven to be not functional because of the weakness of the material , and lower modulus of elasticity which would require building a clasp of non acceptable bulk to compensate for its inherent weakness and generate enough strength to retain a RPD (19). This behavioral difference between metal and polymer could be attributed to the difference in the microstructure level. Metals have small building blocks that are well arranged and highly organized in a dense uniform pattern thus give a rather predictable mechanical behavior in temperatures lower than that of melting point, while that are made up of large strains of polymer molecules, the smaller molecule of polymers can be thousands of times larger than that of any naturally occurring molecules of metal alloys. Plus the fact that polymers have different sizes of molecules contributing to its' structure. These building blocks of polymers are arranged as areas of well organized molecules (the crystalline state) surrounded by areas of curved, twisted & entangled polymer molecules (amorphous state). The amorphous state is responsible for the freedom in movement in any direction of the polymer in temperatures that are considerably lower that the melting temp (20). Deflection fatigue: The results of this study for Co-Cr alloy revealed that the possibility of having a Co-Cr clasp that is subjected to cyclic bending without failure fracture is unlikely to take place even in the minimum deflection of 0.25mm which is in agreement with previous clinical
9

Table 1: Fisher's least significance difference (LSD) analyzing multiple comparisons between groups
Mean Difference Yield Strength .Ultimate Tensile strength CoCr A CoCr A A B B A B B A B B A B B 189.67000* 303.11000* 113.44000* 461.94000* 568.33000* 106.39000* 110.31620 4.86250* -188.17000-* -163.81000-* 24.36000*
*

Std. Error .86026 .86026 .86026 .57241 .57241 .57241 .29820 .29820 .29820 .41083 .41083 .41083

Sig. .000 * .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000

CoModulus of Cr elasticity A CoElongation Cr A

115.17870*

LSD *. The mean difference is significant at the 0.05 level.

Table 2: mean value of cycles required to fracture or permanently deform a sample.


Material A B Co-Cr 0.25 mm. deflection 21272587.5 18795881.1 32210.4000 0.5 mm. deflection 12128790.7 10673335.7 13346.9 1 mm. deflection 7818114.4 6108554 865.7 2.1 mm. deflection 3193095 3045619.7 527.6

Figure 9: A histogram demonstrating a comparison of the mean values of the number of cycles required to fracture or deflect a sample under deflection for the (CoCr) , test group A (Flexite supreme ) and test group B (Commercial Nylon).
Deflection fatigue resistance test results showed that Flexite supreme had the highest mean value at all deflections while the Co-Cr had the lowest mean values and as shown in table 2 & figure 9. Comparing the two test groups for yield strength, ultimate strength and elongation at breakage recorded a high statistical significance. Comparing the two test groups for modulus of
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observations (10) & other fatigue testing (14,21,7) & (17) . This can be attributed to the mechanical properties of the alloy, mainly the E. the proof stress (yield strength) & the elongation values. To explain the results of this study, it seems important that the E of the metals should be considered along with the yield strength (proof stress) property (22). Co-Cr alloys have a high E which is a poor feature concerning clasp design but they do have a good proportional limit (18). Retentive clasp arms are required to have adequate elasticity to deflect out of the retentive undercut, adequate stiffness to produce retention &adequate strength to resist accidental damage (23) . The other mechanical property that may affect the fatigue resistance of a clasp is the ductility of the material which is usually expressed by the elongation values, the ductility of Co-Cr alloy is considered low (brittle material). Co-Cr clasps are more likely to fracture if bent (24), also increased ductility of Co-Cr alloy improved the resistance to fatigue (25). Differences between the materials (Co-Cr alloy& Flexite supreme & commercial Nylon) in deflection fatigue. The difference in the behavior of the samples of the three materials at 0.25mm. & 0.5mm. D and the statistically high significance can be related to the difference in mechanical properties, especially the yield strength, which determines the amount of stress that can build up in the sample (clasp) when deflected. The high yield strength of Co-Cr alloy means that the stresses generated due to deflection can easily pass there proof stress to cause damage or permanent deformation. While the lower yield strength of the Flexite supreme means that considerably lower amount of stress is generated that don't cause the material to fracture or deform (26).

7.

8.

9.

10. 11.

12.

13.

14. 15. 16.

17.

properties of commonly used denture base resins. J Prosthodont; 13:17-27. Morris HF. Asgar K, Tillitson E. "stress relaxation testing. Part 1: A new approach to the testing of removable partial denture alloys, wrought wires- & clasp behavior". J prosthetic Dent 1981; 46(2): 13341. Zavanelli R, Henriques G, Ferreira H, Almeida Rollo J. "Corrosion fatigue life of commercially pure Titanium & Ti-6Al-4V alloys in different storage environments". J Prosthetic Dent 2000; 84(3): 274-9. Brockhurst PJ. "A new design for partial denture circumferential clasp arms". Australian Dental Journal 1996; 41 (5): 317-23. Harcourt HJ. "Fractures of Cobalt-Chromium castings". Br Dent J 1961; 1 10(2): 43-50. Bates JF. "The mechanical properties of CobaltChromium alloys & their Relation to partial denture design". Br Dent J 1965; 119 (9): 389-96. Bates JF." Studies related to the fracture of partial dentures. The functional strain in Cobalt Chromium dentures , a preliminary report". British Dental Journal 1966;120; 79-83. Vallittu PK. Luotio K. "Effect of Cobalt-Chromium alloy surface casting on resistance to deflection fatigue & surface hardness of Titanium". International Journal of Prosthodontic 1996; 9 (6): 527-32. Craig RG. "Restorative Dental Materials", 12 ed. St Louis: Mosby, 2006; Ch 4: 61-4. Earnshaw R. "Fatigue tests on dental Cobalt Chromium alloy". Br Dent J 1961: 110(10): 341-5. Preston JD. "Cobalt-Chromium-Titanium alloy for removable partial dentures". Int J Prosthodontics 1997;10(4): 309-17 Bridgeman J.T. , Marker VA, Hummel SK, Benson BW, Pace LL. "Comparison of Titanium & CobaltChromium removable partial denture clasps'! . J Prosthetic Dent 1997; 78 (2): 187-93.

REFERENCES
1. McGivney GP, Castleberry DJ. "McCracken's Removable Partial Prosthodontics", 11th ed. St Louis: Mosby, 2005; Ch. 1 : 3-4: Ch 6: 85-100: Ch 17: 397,401-402. 2. Glossary of Prosthodontic terms, 7th ed. JPD 2005; (1): 84. 3. R. John Davenport, Evelyn Strauss, and Kelly LaMarco" Aging Knowledge. Enviroment.", 3 October 2001 Vol. 2001, Issue 1, p. vp1. 4. Negrutiu M, Sinescu c, Romanu M, Pop D, Lakatos s (2005). Thermoplastic resins for flexible framework removable partial dentures. Temisoara Med J; 55:29599. 5. Stafford GD, Huggett R, MacGregor AR, Graham J. (1986): The use of nylon as denture base material. J Dent.;14:18 6. Phoenix RD, Mansueto MA, Ackerman NA, Jones RE (2004). Evaluation of mechanical and thermal

18. Bates JF. "Retention of partial dentures". Br Dent J 1980; 149: 171-4. 19. Kaplan 2008. Dentistry Today. Issue date: December 2008, flexible removable partial denture, design and clasp concept". 20. Micheal Sepe. 2008. Ides Articles .Design. http:// www. Ides.com/articles/design/2008/Sepe_02_asp. 21. Asgar K. Peyton FA. "Flow & fracture of dental alloys determined by a micro bend tester". J Dent Res 1962; 41 (1): 142-53. 22. Osborne J, Lammie GA. "Some observations concern Chrome-Cobalt denture bases". Br Dent J 1953; 94(3): 55-66. 23. Kotake M, Wakabayashi N, Ai M, Yoneyama T, Hamanaka H. "Fatigue resistance of Titanium-Nickel alloy cast clasps". Int J Prosthodontics 1997;10(6): 547-52. 24. Noort RV. Lamb DJ. "A scanning electron microscope study of CO-Cr Partial dentures fractured in service "J Dent 1984; 12(2); 122-6 25. Vallittu PK. "Transverse strength, ductility & qualitative elemental analysis of Cobalt-Chromium alloy after various durations of induction melting". J Prosthodontic 1997; 6 (1): 55-60. 26. Craig RG, O'Brien WJ. Powers JM. "Dental Materials: Properties & Manipulations", 6th ed. St Louis: Mosby, 1996; Ch 2:16-26; Ch 11 : 222-5.

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A comparison of the retention of complete denture bases having different types of posterior palatal seal with different palatal forms
Mayada Q. Abdul Khafoor, B.D.S, M.Sc. (1)

ABSTRACT
Background: The most common problem associated with the lack of retention of maxillary complete denture is faulty posterior palatal seal pps. The methods for achieving a pps include arbitrarily scraping the cast, selective pressure technique, and the physiologic impression technique. Material and Method: In this study forces required to dislodge a maxillary complete denture bases were compared for different types of posterior palatal seals (PPS) with different palatal forms by using a specially designed strain gauge force tranducer and strain measuring device. Nine male and female subjects are selected with age range 55-70 years. These patients with different palatal forms according to House's classification of palatal forms: Class I flat, Class II intermediate and Class III high. Using different impression technique the first ordinary impression with Zincoxide eugenol and scraping the cast for pps, the second physiological impression by using korecta wax No.4. Result: The results show very highly significant difference, between the different designs of pps and physiological impression for each group. Conclusion: The physiological impression of pps give better retention because no over compression of tissues (within the physiological limit) and concluded that the form of palate has direct influence on the retention of complete dentures and will aid in the selection of type of posterior palatal seal needed. Keywords: Maxillary complete denture, posterior palatal seal. (J Bagh Coll Dentistry 2012;24(2):11-17).

INTRODUCTION
A well fitting and retentive complete maxillary denture requires a well fitting surface a peripheral border compatible with the muscles and tissues which make up the muco-buccal and muco-labial spaces so that a peripheral seal is created by the soft tissues draping over them and finally, a posterior palatal seal. Avants 1 has shown that "a pps is necessary for optimum retention of maxillary complete dentures" and that of the designs he tested, none proved to be superior in all of his five test subjects1. The pps area has been defined as an area of soft tissue along the junction of the hard and soft palate on which pressure, within the physiologic limits of the tissues, can be applied by a denture to aid in its retention 2. The pps of a maxillary complete denture can be established during the making of the final impression by scoring the final cast, or by incorporating the seal in the finished denture base. The technique can be classified generally as being either functional or empirical 3. Regardless of the technique used or the stage of denture fabrication during which the pps is placed, the objective of its utilization is the same. It provides aperipheral seal by selectively displacing soft tissue to 4: - Provide close tissue contact during speech and swallowing, preventing food and debris from impinging between the denture base and the underlying tissue. - Enhance retention and stability.
(1)Lecturer, Department of Prosthodontics, College of dentistry, Baghdad University.

Provide a thicker posterior border to compensate for processing shrinkage of the denture base in this area5, and - Reduce discomfort when contact occurs between the posterior border of the denture and the dorsum of the tongue 4. The methods for achieving a pps of a maxillary complete denture include arbitrarily scraping the cast prior to denture processing, the selective pressure impression technique, and the physiologic impression technique 6. Winland and Young11 and Chen et al10 stated that the most dental schools teach the method of carving the pps arbitrarily in the maxillary cast. This arbitrarily location and scraping of the definitive cast was found to be the least accurate technique the effectiveness of pps of maxillary complete denture is confirmed only at the insertion appointment. The anterior vibrating line at the area of the junction of the hard and soft palate can be located by palpation of the hamular process and the fovea palatine. The anterior vibrating line serves as the anterior border of the pps area. The posterior vibrating line lies in the junction of the aponeurotic portion of the soft palate and represents the posterior extension of the pps area, they considered a two separate lines of flexion 12. The location and incorporation of the pps on the maxillary definitive cast are often done by the dentist or dental laboratory technician. However these procedures should be the responsibility of the dentist, as the tissue displacement can only be determined clinically 13. A faulty pps may cause
11

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poor retention and /or tissue irritation. Brian M et al 6 describe a technique for the location of the pps intraorally and accurate transfer to maxillary complete denture cast by indelible pencile. Laney and Gonzalez 14 discussed the need for knowledge of the oral cavity's anatomy so that the static surface of the denture base can be balanced against one dynamic tissue surface. In the pps area, the tissues are displaceable and the degree of displacement can be found by palpation with a "T" burnisher 15, by closing both nostrils of the patient and having him blow gently 16 or by visualizing the vibrating line as the patient says "ah" 3. Also, by placing the tissues with various impression materials, a functional or physiologic pps can be impression made as early as the maxillary final impression 18. Another method, scraping the maxillary cast before final processing of the denture, can be used to construct a pps 19. Therefore, the pps takes on many various shapes, size and locations. These various types of pps are discussed by winland and Young11, and their construction as taught in our dental schools is investigated. They discussed that no mather what type of pps is used, the important word is seal-to seal out air and food and to seal in partial pressure and they said that the determination of the posterior limit and palatal seal of the maxillary complete denture is not the technician's obligation, but the responsibility of the dentist. Abedalbaki et al 20 compare the retention of complete denture bases with different types of pps (bead, double bead, and bufferfly). They found no design provide superior priority than the other type of pps but a double beading and butterfly pps can improve the retention of a maxillary complete denture. Determinants of posterior extension: During the final impression appointment, the final extension of posterior border of the maxillary denture is determined. Factors to be considered include: - The drape of the soft palate in relation to the hard palate. A more abrupt relation between the hard and soft palates generally indicates increased muscular functional activity of the soft palate, thus reducing the potential posterior extension of the palatal seal. 4 The shape of palatal vault is related to the activity of the soft palate. The flat vault has the least movable soft palate and the widest area of displacable tissue. In contrast, the high vault or "V" shaped palate often has a soft palate virtually at right angles to the hard palate and is extremely mobile. Thus the area of tissue displaceability is very narrow. The intermediate palatal vault lies between these two extremes 7,21.
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Antolinocolon et al 8 concluded that the form of the palate has direct influence on the retention of complete denture will aid in the selection of the type of posterior palatal seal needed.

MATERIALS AND METHOD


A. The testing apparatus For the purpose of this study, retention has been expressed in term of force required to vertically dislodge a maxillary complete denture using a specially designed strain gauge force tranducer. The data measured by gram 23. The apparatus consist of many parts as shown in figure 1. B. Selection of patients Nine edentulous patients were selected from prosthodontic clinic, college of dentistry, Baghdad University, 6 males and 3 females, the age range between 55-70 years, the criteria used for selection were relatively smooth, firm alveolar ridge covered with healthy mucosa without any posterior under-cuts. The patients with different palatal form according to House's classification of palatal forms: Class I flat palatal vault in the hard palate and Class III a high vault and Class II intermediate between them 7,30. C. Impression techniques: A preliminary impression with impression compound (Quayle Dental, England) was taken and 2 custom trays were fabricated on the study model. Then two impression techniques used: I. First impression technique: 1. Before the border molding procedure, trim and adjust the posterior border of the custom tray 1 to 2 mm distal to the vibrating line. 2. Complete the border molding and make a final impression by using zinc oxideeugenol (ZoE) paste. 3. Remove the impression from the mouth. 4. Mark the vibrating line in the mouth with indelible pencile by using "ah" sound with nose blowing and using the fovea palatinae in locating the vibrating line 24. 5. Reinsert the maxillary impression in the mouth and transfere the location of vibrating line to the ZoE impression. 6. Poured with stone (Zeta, selensor, Industria Zingardi S,r,i, Italy). The water to powder ratio recommended by the manufacturer was used. 7. The master cast was then duplicated once by using heavy body silicon, the

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master cast marked 2 while the duplicated cast was marked 3. II. The second impression technique (Physiological posterior palatal seal). 1. The same steps 1, 2 and 3 used in the previous technique. 2. The anterior vibrating line can be visualized by instructing the patient to say "Ah" with short vigorous bursts while the posterior vibrating line can be visualized by instructing the patient to say "Ah" in short bursts in a normal unexaggerated fashion, then mark the anterior and posterior vibrating lines in the mouth with indelible pencile and transfer the location to the ZoE impression. 3. Kerr Korecta wax No. 4 was used to record the pps area, its a fluid, mouth temperature wax, is preferred for this procedure. It will flow sufficiently at mouth temperature to avoid over displacement of tissues. because the wax continues to exhibit it property of flow in the mouth, it permits the tissues in the area of the pps to rebound, establishing a degree of displacement that is physiologically acceptable. This wax is painting on pps area of impression. 4. Impression is reseated in mouth and held in place for about 3 minutes. Patient is guided and instructed to tip head forward to approximately 30o from vertical position and forcibly place tongue against tray handle or clinician's finger which is supporting tray, this maneuver allow pps area to be recorded in functional position 4,22. 5. Excess wax will be displaced and will flow posteriorly. 6. Impression is removed and examined wax that has flowed posterior to seal is removed with Bard-parker blades, intimate contact between wax and tissues is indicated by glossy appearance of wax in contrast to dull appearance where no contact exists. Wax is painted on where indicated and the impression is reseated intraorally until wax exhibits contact along entire posterior palatal area. 7. After trimming excess wax, impression is reseated for five to eight minutes. During this time, patient intermittently repeats head and tongue positions. This last seating allows tissues in area of pps
Restorative Dentistry 13

to exert their displacing effect on wax, there by achieving functional depth of seal. Figure (2) 8. Impression is carefully beaded and boxed and the impression then poured with stone (Zeta, Selensor, Industria Zingardi s.r.i Italy). The water powder ratio recommended by the manufacturer was used. This cast was marked 1. D. Scraping the casts for incorporation of pps: The casts marked 2 and 3 were scraped to carve certain designs into their posterior palatal areas. No. 4 round bur with a lacron carver were used. The patients classified into groups according to House's cassification of palatal form. Group A (Class I flat palatal form) A1= physiological impression technique of pps A2= scraping the cast 2 according to Housemodified butterfly 3-4mm wide and 1mm deep was carved in the center of the palatal seal area passing through the hamular notches and flushing out on approaching the buccal sulcus 26. A3= Scraping the cast 3 a single bead design as described by boucher 25. A V shaped groove 1mm deep and wide at the base was carved; it passed to rough the hamular notches and flashed out approaching the buccal sulcus. Group B (Class II intermediate palatal form) B1= physiological impression technique of pps B2= Scraping the cast 2 according to Housemodified butterfly 2-3mm wide and 1mm deep was carved in the center of the palatal seal area passing through the hamular notches and flushing out on approaching the buccal sulcus 26. B3= Scraping the cast 3-asingle bead design as described by Boucher 25, like A3 group. Group C (Class III high palatal form) C1= physiological impression technique of pps C2= Scraping the cast 2 according to Housesingle bead design 26 1mm width and depth made on the posterior vibrating line. C3= scraping the cast 3-abutterfly shaped configuration was carved as suggested by Hardy and Kapur 3. An angled groove 1.0mm deep and 1.5mm wide at the base was carved in the center of the palatal seal area passing through the hamular notches and flushing out on approaching the buccal sulcus Figure (3).

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E. Construction of the test denture bases: Identical denture bases for the pps were made on cast 1, 2 and 3 for each group and were designated 1, 2 and 3 respectively. Base plate was formed for each of the casts using two mm thick layers of base plate wax, the bases were processed using heat curing acrylic resin (Quayle Dental, England). F. Clinical testing Astringe of about 1 inch length was secured on the polished palatal surface of each of the maxillary denture bases in region relating to the second premolar and first molar teeth 14, 20 , with auto polymerizing acrylic assembly (Figure 4). The dislodging force that is directed to the maxillary denture bases was applied at the middle of the denture base where the middle location is considered the most reliable region for testing the retention of complete maxillary denture 15. All tests for a subject were completed in one appointment; all the denture bases for that subject were stored in water for the same length of time before being tested for retention. Thus, the time of day and water sorption was not variables. The patient head was held firmly on the head rest with occlusal plane parallel to the floor. Figure (5) all measurements of retention involving in a given subject were conducted at one sitting, each test denture base was subjected to three retention tests. The force values at which the denture base was dislodged completely from the palate at a steadily increasing force was displayed on strain measuring device represented by gram, the force values in grams could be calculated.

The mean values of the statistical analysis for the data of group C (deep palatal form) between the three groups C1, C2 and C3 as shown in Table (5). The results of ANOVA table with LSD as shown in Table (6). The results explained that there was a very highly significant difference between groups and between groups (C1 and C3) and between (C2 and C3) groups. While a non significant difference between (C1 and C2) groups.

DISCUSSION
An adequate seal of the posterior border of a maxillary complete denture is essential for retention. Establishing the pps at final impression stage confirm the effectiveness of the pps and allows the dentist to control its location and the amount of tissue displacement 10,27. This is agree with the result of this study which revealed that the physiological impression technique of pps area give better retention for complete denture base than the other technique of pps. Vintion 28 stated, "where the tissues move in normal function is the area where maximum peripheral seal can be achieved with the least amount of tissue displacement. This appears to be best physiologically. It is maximum result with minimum activity 11. The route of the vibrating line from one side of the palate to the other is not of a definite pattern but varies with the shape of the palate. This variation is such a constant observation that palate or throat forms have been classified as Class I, Class II and Class III. Class I indicates a low, flat vault in the hard palate which continues into a soft palate that has a minimal amount of drop and movement. This situation permits a more distal extension of the maxillary denture and provides broader pps area 17. This agree with the result of group A, it was found that the physiological impression technique and modified butterfly 34mm width for pps area give better retention than the single bead design of pps. Nikoukar 17 and Swenson and Terkla 9 were found that the flat palatal shape has vibrating line located farther posteriorly. While in Class III indicates a high vault in the hard palate and an acute drop and maximal movement in the soft palate. The region where this acute drop occurs becomes extremely critical because it places greater limitations on the distal extension of the maxillary denture and will accommodate only a narrow pps 17. This agree with the result of group (C) which revealed that the physiological impression technique of pps and single bead design of House give better retention for complete denture base than the butterfly shape
14

RESULTS
The mean values of the statistical analysis for the data of group A (flat palatal form) between the three groups of A1, A2 and A3 were shown in Table 1. Where as the results of ANOVA table with LSD as shown in table 2. The results explained that there was a very highly significant differences between the groups and between (A1 and A2) and between (A1 and A3) and between (A2 and A3) groups. While the mean values of the statistical analysis for the data of group B (intermediate palatal form) between the three group B1, B2, and B3 as shown in Table (3). Where as the result of ANOVA table with LSD as shown in Table (4). The result explained that there was a very highly significant difference between groups and between groups (B1 and B3) and between (B2 and B3), while there was a non significant differences between groups (B1 and B2).
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of pps (Hardy and Kapur) 3. Nikoukari 17, Swenson and Terkla 9 found that the higher the vault the more abrupt and forward is the vibrating line. While the Class II designates those palatal forms which are intermediate between Class I and Class III 17. This agree with the result of group B which revealed that the physiological impression of pps and modified butterfly 2-3mm width according to House give better retention for complete denture base than the single bead design of pps (Boucher). The mucosal tissues of the pps area vary in displaceability from patient to patient, the task of determining the shape, size and depth of the seal must be accepted by the clinician and should not be assigned to the Laboratory technician. It is quite improssible to establish the posterior limit, the width and depth of the seal in an edentulous cast alone, and it is the clinician's responsibility to make the decision based on proper procedures in the mouth.

REFERENCES
1. Avants WE. A comparsion of the retention of complete denture bases having different types of posterior palatal seal. J Prosthet Dent 1973; 29(50): 484-93. 2. Roland LE, Forrest RS. The posterior palatal seal. A review. Australin Dent J 1980; 25 (4): 197-200. 3. Hardy IR, Kapur KK. Posterior border seal its rationale and importance. J Prosthet Dent 1958; 8(3): 386-7. 4. Gerald SW. Establishing the posterior palatal seal during the final impression procedure: a functional approach. J Am Dent Assoc 1977; 94: 505-10. 5. Anthony DH, Peyton FA. Dimensional accuracy of various denture base materials. J Prosthet Dent 1962; 12: 67-81. 6. Brian W, Robert F. Accurate location of posterior palatal seal area on the maxillary complete denture cast. J Prosthet Dent 2006; 96 (6): 454-5. 7. Sudhakara VM, Sudhakara UM, Karthik KS, Udita SM. A review on Diagnosis and treatment planning for completely edentulous patients. JIADS 2010; 1(1): 1621. 8. Colon AK, Kotwal K, Mangelsodroff AD. Analysis of the posterior palatal seal and the palatal form as related to the retention of complete dentures. J Prosthet Dent 1980; 47(1): 23-7. 9. Swenson MG, Terkla LG. Complete denture. 6th ed. St Louis: The C.V. Mosby company; 1970. pp. 65-70, 372-6.

10. Chen MS, et al. Methods taught in dental schools for determining the posterior palatal seal region. J Prosthet Dent1985; 53: 380-3. 11. Winland RD, Young JM. Maxillary complete denture posterior palatal seal: variation in size, shape and location. J Prosthet Dent 1973; 29(3): 256-61. 12. Vernie AF, Chitre V, Aras M. A study to determine whether the anterior and posterior vibrating lines can be distinguished as two separate lines of flexion by unbiased observer: Apilot study Indian J of Dental Research 2008; 19(4): 335-9 [IVSL]. 13. Winkler S. Essentials of complete denture prosthontics. 2nd ed. St. Louis: Ishiyaku Euro America; 1994. 14. Laney WR, Gonzalez JB. The maxillary Denture: Its palatal Relief and posterior palatal seal. J Am Dent Assoc 1967; 75: 1182-7. 15. Bylicky HS. Variable Approaches in obtaining a posterior palatal seal: Description of Technique. NYJ Det 1966; 36: 280-2. 16. HeartWell GM, Rhn AO. Syllabus of complete dentures. 1st ed. Philadelphia: Lea and Febiger publishers; 1968. 17. Nikoukari H. A study of posterior palatal seal with varying palatal forms. J Prosthet Dent 1975; 34: 60513. 18. House MM. Full Denture Techniques study club No.1, 1950. 19. Stephens AP. Upper full denture retention. J Irish Dent Assoc 1968; 14: 131-2. 20. Mohammed AA, et al. Company required dislodging forces between different types of posterior palatal seal. Mustansiria Dent J 2006; 3(1): 97-101. 21. Watt DM, Mac Greagor AR. Designing complete dentures. Philadelphia: W.B. Saunders company; 1976. 83-6. 22. Silverman SI. Dimension sand displacement patterns of posterior palatal seal. J Prosth Dent 1971; 25: 470. 23. Ilham HAA. The effect of three different denture adhesives on the retention of mandibular complete denture (comparative study). A master thesis, College of Dentistry, University of Baghdad, 2008. 24. Behnoush R, Vicki CP. Current concepts for determining the posterior palatal seal in complete denture. J Proth Dent 2003; 12(4): 265-70. 25. Boucher CO. Swensons complete dentures. St. Louis: The C.V. Mosby Co.; 1964. Pp. 115, 453-60. 26. Sudhakara V M, Karthik KS. A review on posterior palatal seal. JIADS 2010; 1(1):16-21. 27. Ansari HI. Estabishing the posterior palatal seal during the final impression stage. J Prosthe Dent 1997; 78(3): 324-6. 28. Vinton PW. Posterior palatal seal. personal communication, 1971.

Table 1: Means and standard deviation of Group A


Group A A1 A2 A3 Total Restorative Dentistry Mean 309.3333 186.0000 119.6667 205.0000 15 N 3 3 3 9 Std. Deviation 17.92577 12.16553 13.61372 84.33119

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Table 2: ANOVA and LSD of group A


Group A Between Groups Within groups Total Group A A1 A2 A3 A2 A3 Sum of squares 55584.667 1309.333 56894.000 df 2 6 8 Mean square 27792.333 218.222 F 127.358 Sig. 0.000

Mean Difference (I-J) 123.33333 189.66667 66.33333

Std. Error 12.06157 12.06157 12.06157

Sig. 0.000 0.000 0.002

The mean differences is significant at the 0.05 level

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


Group B B1 B2 B3 Total Mean 490.0000 480.0000 257.0000 409.0000 N 3 3 3 9 Std. Deviation 10.00000 20.00000 23.30236 115.21936

Table 4: ANOVA and LSD of group B


Group B Between Groups Within groups Total Sum of squares 104118.000 2086.000 106204.000 df 2 6 8 Mean square 52059.000 347.667 F 149.738 Sig. 0.000

Group B B1 B2 B3 B2 B3

Mean Difference (I-J) 10.00000 233.00000 223.00000

Std. Error 15.22425 15.22425 15.22425

Sig. 0.536 0.000 0.000

The mean differences is significant at the 0.05 level

Table 5: Means and standard deviation of Group C


Group C C1 C2 C3 Total Mean 399.3333 392.6667 244.3333 345.4444 N 3 3 3 9 Std. Deviation 6.02771 11.23981 41.78915 78.97011

Table 6: ANOVA and LSD of Group C


Group C Between Groups Within groups Total Group C C1 C2 C3 C2 C3 Sum of squares 46072.222 3818.000 49890.222 df 2 6 8 Mean square 23036.111 636.333 F 36.201 Sig. 0.000

Mean Difference (I-J) 6.66667 155.00000 148.33333

Std. Error 20.59666 20.59666 20.59666

Sig. 0.757 0.000 0.000

The mean differences is significant at the 0.05 level

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Figure 1: Strain gauge force tranducer

Figure 2: Physiological impression of pps

Figure 3: All casts of each groups

Figure 4: Astring of 1 inch in length on the polished surface

Figure 5: The patient during testing procedure

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An evaluation of the

An evaluation of the use different techniques of the thermoplasticized obturators on the coronal seal
Mervat M. Al-Bakri, B.D.S., M.Sc. (1) Hussain F. Al-Huwaizi, B.D.S., M.Sc., Ph.D. (2)

ABSTRACT
Background: The aim of the present study was to evaluate coronal leakage of root canals obturated by various techniques. Methodology: Straight single rooted teeth with mature apices (6 groups of 10 teeth each). Root canals were prepared according to the crown down technique using hand ProTaper system. Endofill root canal sealer and 2.5% sodium hypochlorite was used. Root canals were obturated using cold lateral condensation Thermafil and Soft Core obturation after root canal filling the six groups was divided into two individual groups of 30 teeth. The first group of 30 teeth was kept for 1 week the second 3 week at 37 oC. Teeth were immersed in india ink. Each was split and sectioned longitudinally and the maximum extent of leakage was measured using a stereomicroscope Results: Leakage occurred whatever filling technique was used the number of teeth with gross leakage decreased with time up to 3 weeks. There were significant differences in coronal leakage between the various obturation techniques after 1 week, and after 3 weeks. No statistically significant differences were found between soft-Core and cold lateral condensation after 1 week and statistically significant differences were found after 3 weeks. There were statistically significant differences between Thermafil and lateral condensation after 1 week and no statistically significant differences after 3 weeks. Conclusion: Under the conditions of the present study none of the gutta-percha obturation techniques prevented coronal leakage. Coronal leakage increased during the first week for CLC, Thermafil and Soft-Core obturators, and decreased after 3 weeks. Coronal leakage in the Soft-Core obturators was higher than Thermafil and CLC after one week. Thermafil coronal leakage was lower than others after one week. Coronal leakage in the Soft-Core obturators higher than Thermafil and CLC after three weeks coronal leakage was equal in Thermafil and CLC after three weeks. Keywords: Endofill root canal sealer HPT, leakage, obturtion, CLC, Thermafil, Soft-Core. (J Bagh Coll Dentistry 2012;24(2):18-20).

INTRODUCTION
The provision of a well-compacted and highly tightly adapted root filling is one of the goals of root canal treatment. However, contemporary obturation techniques and filling materials do not seal completely the root canal system up to the level of the cemento-enamel junction. Moreover, it is accepted that both apical and coronal leakage can occur following apparently successful root canal treatment (1, 2). Several factors appear to influence the extent of both apical and coronal leakage. Furthermore, various root canal filling techniques based on heated or preheated guttapercha have been introduced in order to enhance complete filling of the root canal. These include warm vertical condensation (3), warm lateral condensation (4), thermatic compaction (5), hybrid condensation, i.e. a combination of cold lateral condensation and thermomechanical compaction (6) , thermoplasticized gutta-percha as a coating on a flexible carrier (7), and injection moulded thermoplasticized guttapercha (8). The aim of the present study was to evaluate coronal leakage of root canals obturated by various techniques.
(1) Assistant lecturer. Department of Conservative Dentistry. College of Dentistry, University of Baghdad. (2) Professor. Department of Conservative Dentistry. College of Dentistry, University of Baghdad

MATERIAL AND METHOD


Sixty extracted human straight single-rooted teeth with mature apices were used in this study. Both carious (limited occlusal and/or interproximal lesions without pulp exposure) and non-carious teeth were included. All teeth were stored in 10% formalin until the sample was completed. Sample preparation The crowns were removed 2mm above the cement-enamel junction with a high-speed fissure bur and water spray. After gross removal of pulp tissue, a size 10 Flexofile was introduced into the canal until it could be seen in the major apical foramen. The working length was determined by subtracting 1 mm from this length. The root canals were prepared by means of a crown-down technique, using the Protaper Hand system until F3. The canals were copiously irrigated with 2.5% sodium hypochlorite solution with a 27 gauge endodontic needle. The canals were dried with paper points and the patency of the apical foramen was confirmed with a size 10 Flexofile. The roots were randomly divided into 6 experimental groups of 10 roots each.
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Following drying with paper points, the canals were obturated by one of the following techniques. Group 1: Cold lateral condensation of guttapercha A standard size g.p cone that matched the master apical file was fitted to the working length with atugback Endofill root canal sealer was mixed according to the manufacturer's instructions and placed in the canal by coating the cone with sealer and gently seating it at the working length. Lateral condensation was then carried out using size 20 and 25 accessory g.p cones with endotontic finger spreader placed within 1 mm of the working length. The g.p cones coated with sealer were laterally condensed until they could not be introduced more than 3mm into the root canal. Following obturation, the g.p was removed from the coronal cavity up to the level of CEJ with a warm instrument and vertically condensed with Machtou pluggers. Group 2: Thermafil obturation The correct size of the plastic core thermafil obturator was selected using the verification kit. The obturators were then placed in the Thermaprep oven according to the manufacturer's instructions. The sealer was sparingly introduced into the canal, after which the plasticized thermafil device was inserted to the apical stop. The shank of each carier was cut at the canal orifice using an inverted cone bur in a high speed hand piece and the g.p was compacted vertically with a plugger. Group 3 Soft core obturation The correct size of the plastic core Soft-Core obturator was selected using the size verifier. The obturators were then placed in the Soft Core Over (Soft Core System). When the oven indicated that the obturator was ready, it was removed from one of the slots in the top of the oven endofill sealer was sparingly introduced into the canal, after which the plasticized Soft Coe device was inserted into the apical stop. The handle and insertion pin were removal by a twisting motion. Excess plastic core material was removed with a small inverted cone bur and any extra g.p removed. The g.p was then compacted vertically with a Machtou plugger. Staining, longitudinal splitting and dye measurement After obturation, the teeth were stored in 100% humidity for 48 hr. to ensure the sealer was set. The roots were covered with a nail varnish, the first coat was allowed to dry and a second coat was applied. All teeth were immersed in a bath of India ink and stored at 37oC for 1 week and the
Restorative Dentistry 19

other 3 groups for 3 weeks. After which they were thoroughly washed with running water. The nail varnish was removed, the teeth were then air dried. Longitudinal shallow grooves were made on the buccal and lingual surface with a rotating diamond disc of small diameter under continous water cooling, and the teeth carefulyl fractured and sectioned with a sharp chisel. The degree of microleckage was determined by measuring the linear extent of India ink penetration from the surface of the coronal g.p at the level of the amelocemental junction to the position of the maximum dye penetration apically (coronal leakage testing). To eliminate bias, coronal leakage were measured independently by two evaluators who were unaware of the obturation techniques used. All measurements were obtained by means of a stereo microcope with calibrated scale ocular.

RESULTS
The teeth showed dye penetration along the entire length of each root canal. No significant differences amongst the observers were scored, so that the calculation of the average leakage values of the two observers for each root was justified. Since the data indicated a non-normal distribution, leakage was assigned using the following categories: Coronal leakage was measured to the deepest point. Statistical analysis was carried out using the ANOVA test between six groups to determine whether there were significant differences between the groups. Pairs of groups were compared using the LSD or t-test. Linear coronal leakage of the experimental roots The result for coronal leakage is provided in table 1. There were significant differences in coronal leakage between the various obturation techniques after 1 week, and after 3 weeks. According to the t-test statistically significant differences were found between Soft-Core obturators and Thermafil after 1 week and after 3 weeks. No statistically significant differences were found between soft-Core and CLC after 1 week and statistically significant differences were found after 3 weeks. There were statistically significant differences between Thermafil and lateral condensation after 1 week and no statistically significant differences after 3 weeks.

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Table 1. Descriptive statistics of the groups

differences in methods of measurement of coronal leakage also the result of this study was in agreement with Saunders and Saunders (12) in which after 7 days, there was significantly less leakage in these teeth obturated with Thermafil.

REFERENCES
1. Hovland EJ, Dumsha TC. Leakage evaluation in vitro of the root canal sealer cement sealapex. International Endodontic Journal 1985; 18: 179-82. 2. Saunders WP, Saunders EM. Coronal leakage as a cause of failure in root canal therapy: a review. Endodontics and Dental Traumatology 1994; 10: 15-8. 3. Schilder H. Filling root canals in three dimensions. Dental Clinics of North America 1967; 11: 73-44. 4. Endotec Thermal Endodontic Condenser System. The warm lateral condensation Technique Clinical Manual. Dentsply Int. Inc. Milford DE. USA: The LD Caulk Division. 1986. 5. Mc Spadden JT. Self study Course of the Thermatic Condensation of Gu Ha Bercha. Dentsply Int. Inc. Milford DE. USA: LD Caulk Division. 1980. 6. Tagger M, Tamse D, Katz A, Korzen BH. Evaluation of the apical seal produced by a hybrial root canal filling method, combining lateral condensation and thermatic compaction. Journal of Endodontics 1984; 10: 299-303. 7. Johnson WB. A new gutta-percha technique. Journal of Endodontics 1978; 4: 184-8. 8. Yec FS, Marlin J, Krakow AA, Gron P. Threedimensional obturation of the root canal injection molded, thermoplasticized dental gutta-percha. Journal of Endodontics 1977; 3: 168-74. 9. Wu MK, Wesselink PR. Endodontic leakage studies reconsidered Part I: Methodology, application and relevance, International Endodontic Journal 1993; 26: 37-43. 10. Dalat DM, Spangberg LSW. Comparison of apical leakage in root canals obturated with various guttapercha techniques using a dye vacuum tracing method. Journal of Endodontics 1994; 20: 315-9. 11. Kontakiotis E, Chaniotis A, Georgopoulou M. Fluid filtration evaluation of 3 obturation techniques 2007. 12. Saunders WP, Saunders E. Influence of smear layer on the coronal leakage of thermafil; laterally condensed guttapercha root fillings with a glass ion sealer, 2012.

Figure 1: The coronal leakage of the different groups in different times

DISCUSSION
In order to evaluate the sealing ability of root fillings, several in vitro methods have been designed. It is important to appreciate that not only is the apical seal of the root canal of importance, but the coronal seal is of equal importance for the success of treatment (9). The most common method used to assess leakage remains the measurement of dye penetration (9). The result of dye penetration studies, however, is confusing and often results in variable conclusions (10). This lack of agreement has been discussed by Wu and Wesselink (9), who questioned, the validity of leakage studies and recommended that more research should be devoted to leakage study methodology. Longitudinal sectioning of roots and the linear measurement of dye penetration were used in the present study for the measurement of leakage. Splitting the root longitudinally combined with dye penetration enable the demonstration of the pattern of dye penetration. In the present study obturation with soft core obturators resulted in greater leakage scores. This may indicate that Soft Core obturators are in effective these might be related to Soft Core has less taper core so more gutta percha-core ratio than Thermafil therefore it exerts more contraction. In addition, it was also seen that coronal leakage decreased with time up to 3 weeks in all three obturation techniques. In this study we found that Thermafil coronal leakage was lower than other obturation techniques and this result was disagree with Kontakiotis et al (11). These might be related to the
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An evaluation of apical

An evaluation of apical microleakage in roots filled with thermoplastic synthetic polymer based root canal filling material (RealSeal 1 bonded obturation)
Nadine J. Adbul-rada, B.D.S. (1) Adel F. Ibraheem, B.D.S., M.Sc. (2)

ABSTRACT
Background: This study aimed to evaluate and compare the apical microleakage of roots canal filled with cold lateral condensation of gutta-percha, cold lateral condensation of Resilon, Thermafil and RealSeal1 bonded obturation. Materials and methods: Sixty freshly extracted maxillary first molars with straight palatal roots .Using diamond disc bur with straight hand piece and water coolant the palatal roots of teeth were sectioned perpendicular to the long axis at the furcation area. All roots were prepared with crown-down technique using hand ProTaper system (Sx-F4).The prepared roots randomly divided into 4 groups of fifteen roots each; the groups obturated with different obturation technique. In Group 1 roots obturated with( lateral condensation of gutta-percha), Group 2 was obturated with(lateral condensation of Resilon),group3 was obturated with (Thermafil) while in group4 obturated with( RealSeal 1 bonded obturation).All the samples sealed coronally and stored in normal saline at 37C for one week ,then all the roots submerged Indian ink for one week. The roots were cleared and the degree of linear dye penetration was measured in millimeter by stereomicroscope under 40X magnification with calibrated scale ocular grid. Results: The results showed that the RealSeal1 bonded obturation leaked apically significantly higher than other test groups, while the group of lateral condensation of gutta-percha exhibited the least value of apical microleakage. Conclusion: The complete hermetic apical seal cannot be created neither with gutta-percha nor with Real Seal 1bonded obturation. Keywords: Apical microleakage, gutta-percha, RealSeal 1bonded obturation. (J Bagh Coll Dentistry 2012;24(2):2126).

INTRODUCTION
Complete obturation of the root canal with an inert filling material and creation of a fluid-tight seal are among the major goals of successful endodontic treatment (1).The main three functions of obturation are to entomb any bacteria remaining within the root canal system; to stop the influx of periapical tissue derived fluid from entering the root canal to feed the surviving bacteria; and to prevent coronal leakage of bacteria. Although gutta-percha has many desirable properties, including chemical stability, biocompatibility, non porosity, radiopacity and the ability to be manipulated and removed, it does not always meet the three functions of obturation(2). Gutta-percha does not bond to the internal tooth structure, resulting in the absence of a complete seal (3).Many attempts have been made to resolve the problem through the variation in obturation technique including vertical and lateral condensation and the use of reverse-fill or touch and heat system. These methods have reduced microleakage to ascertain degree but still have failed to eliminate ( ). the problems 4
(1)M.Sc. student, dep. of conservative dentistry, college of dentistry, university of Baghdad. (2)Professor dep. of conservative dentistry, college of dentistry, university of Baghdad.

In 2004, a new core material Resilon (Resilon Research LLC, Madison, CT, USA) in conjunction with an adhesive system (Epiphany, Pentron Clinical Technologies, Wallingford, CT, USA) was introduced to the market. Thisthermoplastic-filled polymer core polycaprolactone-based has potential to challenge gutta-percha the gold standard as a root filling core material (5). Resilon is a thermoplastic synthetic polymer- based root canal filling material. Based on polymer of polyester, Resilon contains bioactive glass and radiopaque fillers. Epiphany is a dual curable resin composite used as a sealer combined with Resilon points. According to manufacturer, Epiphany sealer bonds both to dentin and also to root canal filling material. This may be an important fact to eliminate microleakage since it is well-known that microleakage occurs not only through sealerdentin but also through sealer and root canal filling material Interfaces (6,7).

MATERIALS AND METHODS


Samples Selection Sixty freshly extracted maxillary first molars teeth. The criteria for teeth selection Straight root canal mature centrally located apical foramen, patent apical foramen, roots devoid of any
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resorption, cracks or fracture and the palatal roots will be 10mm in length from the apex up to furcation area(8). Samples preparation After extraction, all teeth will be stored in distilled water at room temperature. Any soft tissue remnants on the root surface were removed with sharp periodontal curette. The crown of the tooth was sectioned perpendicular to the long axis of the root at the furcation area with a disc diamond and the root length adjusted to 10mm from flat reference point to the root apex. The patency of the canal was checked by passing# 10 K file 1mm through the apical foramen and the working length equal to 9 mm. Silicon rubber base (heavy body) was mixed (Base and catalyst) according to the manufacturer instructions loaded with hand and inserted it in a perforated plastic container (dimension 13mm, height 52mm) using spatula to adapt heavy body to the wall of the plastic container then the sectioned root centered inside the rubber base. Heavy body left to set forming small blocks to facilitate handling of roots during instrumentation and obturation. The canals were prepared with crown-down technique using (hand use) Protaper system (Sx to F4). According to the manual instruction, the motion of instrumentation was clockwise reaming action with sufficient apical pressure till the file engaged the dentin about four rotations at each time till the file became passive, then the file was pulled and its flutes cleaned from the dentin debris frequently and inspected for any sign of distortion. Obturation of the roots: Group 1: In this group roots were obturated with cold gutta-percha points (lateral condensation technique) using AH-26 sealer. AH-26 was mixed a, on a dry, clean glass slab with spatula. The mixture had a homogenous creamy consistency that string out at least one inch when the spatula was raised slowly from the glass slab. The canal was dried using paper point and sealer was introduced into the canal to full working length using file F4 by pumping action of the file with simultaneous rotary movement in a counterclock direction to coat the canals with 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 in the canal. The previously checked finger spreader size 35 is inserted between the master cone and the canal wall within 1-2 mm from the working length. Spreader taper is the mechanical force that laterally compresses and spreads gutta-percha creating a space for additional accessory cones. The tip of accessory point size #20 was dipped in the sealer and inserted into the canal by space left
Restorative Dentistry 22

by the spreader; this was followed by more spreading and more accessory cone until the spreader could not enter more than 2-3 mm into the canal orifice. When obturation of teeth was accomplished, the excess gutta-percha removed with heated endodontic plugger to a level (1mm) higher than the coronal end of roots and vertically condensed with root canal plugger, so the guttapercha obturate the entire canal up to the coronal terminus. The roots were coronally sealed by temporary filling. Group 2: In this group roots were obturated with Resilon and Real Seal SE sealer by lateral condensation technique. The dual syringe (with mixing tip) was used to express the sealer onto the mixing pad then the sealer was carried to the canal on the paper point according to manufacturer instruction .The master cone size 40 was coated with the sealer and placed into its correct working length within the canal. A finger spreader size 35 was inserted between the master cone and the canal wall within 1-2 mm from the working length. Spreader taper is the mechanical force that laterally compresses and spreads Resilon creating a space for additional accessory cones. The tip of accessory point size #20 was dipped in the sealer and inserted into the canal by space left by the spreader; this was followed by more spreading and more accessory cone until the spreader could not enter more than 2-3 mm into the canal orifice. The excess Resilon was seared off with a hot endodontic plugger and vertically was condensed with endodontic plugger and then the coronal third of each root was cured using the light curing device for 40 seconds according to manufacturer instruction. The coronal 1 mm of each root sealed with glass ionomer cement as a temporary restoration according to manufacturer of Real Seal system. Group3: In this group roots were obturated by Thermafil cones and AH-26. The stoppers were placed on the cone according to the working length and then the matching size verifier was inserted into the canal to the working length. The sealer was introduced into the canal in the same manner as Group 1. Thermafil cones (size 40) were placed in one of the heating chamber of ThermaPrep plus oven (Size 30-60 button is chosen). After beep sound, the oven was switched off then the cone raised without rotation and inserted inside the canal firmly and slowly to working length without any twisting or rotation. The handle was removed after the gutta-percha cooled by inverted cone bur in high speed hand piece. The roots were coronally sealed by temporary filling (Citodur).

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Group4: In this group roots were obturated with Real Seal 1 obturator and Real Seal SE sealer according to manufacturer instruction. The stopper was placed on the matching size verifier and then it inserted into the canal to the working length. The verifier should fit passively in the canal. Then RealSeal 1 (size 40) were placed in one of the heating chamber of RealSeal 1 oven (Size 40-60 button is chosen). The heating time needed to heat RealSeal1was regulated automatically about1:30 minutes, during this time SE sealer was dispensed and introduced to the canal in the same manner as Group 2. After the first beep signal the obturator is ready for removal from the unit and inserted in the canal within 6 seconds without any twisting or forcing. The handle and the shaft were removed with inverted cone in a high speed hand piece then was light cured the coronal surface of the RealSeal1 obturator for 40seconds. The coronal 1 mm of each root sealed with glass ionomer according to the manufacturer instruction. Sample storage: After obturation the samples were stored in incubator at 37C for a week to ensure complete setting of the sealer (9). Leakage study: Each group had one root as a negative control and one root as a positive control. The negative control roots were coated completely with one layer of nail varnish and two layers of sticky wax, while positive control roots were left uncoated .While each experimental root was coated with one layer of nail varnish and two layers of sticky wax except for the apical 2mm. Indian ink was used as leakage indicator for all groups (10).A puncher was used to make hole in the center of the rubber cap to create space into which the coronal third of each root passed and fixed to rubber cap. The apical 3 to 4 mm of each root was immersed in a glass vial containing Indian ink and deposited in an incubator at 37C for a week. At the end of this period, the roots were removed from the ink and washed under running water in a position opposite to the apical foramen for one minute. The sticky wax was scraped from the root surface with a lacron carver and washed again under running water (10). Clearing process: The roots were decalcified (the tooth can be pricked by sewing pin) with 5% nitric acid for a period of 5 days, renewing the acid daily. The roots were then washed under running tap water for 30 minutes and dehydrated by 99-100% ethyl alcohol for 3 days with daily change of alcohol, and then all the roots became transparent by immersion in methyl salicylate for 24hours (11).Linear dye penetration was measured from the apical foramen to the maximum extension of the dye using light stereomicroscope
Restorative Dentistry 23

under 40X magnification with calibrated scale ocular to establish the degree of apical dye penetration in millimeters.

Figure 1: The cleared sample of Real Seal 1 bonded obturation.

RESULTS
Table 1: Descriptive statistic of analysis for experimental groups
Group N Mean S.D SE Min max 1 13 0.4385 0.08697 0.02412 0.30 0.60 2 13 0.8692 0.16013 0.04441 0.40 1.00 3 13 0.5115 0.13095 0.03632 0.30 0.75 4 13 0.9154 0.08987 0.02493 0.80 1.00

Table 1 shows that, group 1 (lateral condensation of Gutta-percha) have the lowest mean value of dye penetration (0.4385) while the highest mean value of dye penetration was for group 4 (Real Seal 1) (0.9154). The rest values of other groups were fluctuation between these values. To identify the presence of statistically significant difference for apical dye penetration between groups, ANOVA test and t- test was carried on. The results of t-test showed that there is a high significant difference between all the groups except for 1&3 and for2&4 the difference was non-significant.

DISCUSSION
Three dimensional sealing of all portals of exist present in the root canal system have been the ultimate goal of different obturation materials and techniques for many decades. Perfect adhesion qualities achieved by newer bonding systems tempted clinicians to adopt such technology in an attempt to provide better seal for the root canal system. A new resin obturating materials RealSeal1 was tested in the present study for its ability to provide three dimensional sealing for root canals. In this study the maxillary first molar have been used ,the palatal roots were sectioned at the furcation area to eliminate the variables in access preparation design, since if the crown present each tooth would1 and to get flat reference point for measurements(12).Root canals were prepared using ProTaper hand system

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because it provide minimum degree of apical microleakage when compare with Rotary ProTaper(13).EDTA was used as irrigant in order to remove the smear layer because many studies advocate its removal to reduce microleakage(14) also deionized water is used as a final irrigant according to manufacturer instruction. AH-26 sealer was selected and used in this study because have the lowest leakage value compared with other types of endodontic sealer (15).SE Real Seal sealer have been used with a synthetic polymerbased core material (Real Seal 1, Resilon) a according to the manufacturer instruction. 4.2 Leakage studies constitute a major part of contemporary endodontic research. .The most common method used remains the measuring of liner penetration of dye, but the nature and amount of leakage observed with this technique cannot be extrapolated to an in vivo situation. Measurements of dye penetration were made after decalcifying and clearing the root which it renders the root transparent, enables three dimensional observation of the dye penetration, which can be recorded to its maximum extent and also evaluate whether or not associated with porosities, the presence of empty spaces and stripping of guttapercha from solid core system(16).This explains using clearing method for measuring microleakage for this study. This method commonly used because it is easily accomplishes and does not require sophisticated materials (17-19). 1. Real Seal 1 and Resilon: In this in vitro study, the highest mean of leakage value was observed in RealSeal1 and Resilon with no significant differences, this might be related to same composition of materials and both contain methacrylate monomer. 2. Real Seal 1, Gutta-Percha and Thermafil: The Real Seal 1 showed the most leakage value with highly significant difference was found with gutta-percha and Thermafil groups. This might be related to that the methacrylate-based materials undergo volumetric shrinkage during the polymerization process(20-22) also the root canal have high cavity configuration factor that contribute to polymerization stresses created by resin-based materials along root canal walls(23). Tay et al.(24)found that polymerization of the sealer may be promoted by heat generated during softening of the material. Another plausible explanation for high leakage value is that the resin sealer should be light cured for 40 seconds to create an immediate coronal seal according to instruction, this prevents stress relief by resin flow and the resin sealer may detach from dentin walls thus creating interfacial gaps(25, 26). The results of present study disagreed with Testarelli et
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al.,(27),they found that the new RealSeal1 material (carrier-based Resilon) showing significantly better sealing ability than the traditional carrierbased gutta-percha systems, this may be explained by different evaluation method because they used fluid filtration method and also disagree with study conducted by Duggan et al.,(28) that found that RealSeal1 appeared to resist bacterial penetration more effectively than Thermafil this disagreement may be attributed to their study which is carried on a dog model after inoculation coronally for 4 months. 3. Resilon, Gutta-Percha and Thermafil The Resilon showed higher leakage value and a highly significant difference was found with gutta-percha and Thermafil groups, this may be related to the same reasons that are mentioned in paragraph 4.2, in addition to that inadvertent stripping of sealer off the canal wall during placement of cones (29, 30) and disruption of the maturing resin root dentin bond during lateral condensation or other technique(29, 30).The results of present study were in agreement with(31,32,33)and disagreed with Lumnije et al.(34) they found that Resilon had less dye penetration in comparison with gutta-percha and this may be related to different type of sealer used and different method of evaluation because they used dye extraction determined with spectrophotometer. Wedding et al.(35) found that Resilon exhibited a statistically significant increased resistance to fluid movement compared with gutta-percha and AH-26 sealer. This may be due to different method of preparation and different evaluation methods because they used fluid filtration microleakage test. 4. Gutta-percha and Thermafil :In this in vitro study, lateral condensation of gutta-percha group show the least leakage with non-significant difference with Thermafil group which they provides best apical sealing .This finding was in agreement with(36-38,10,39)while these results disagreed with Inan et al.(40)found that Thermafil have the lowest mean leakage values than the highest were observed for lateral condensation of gutta-percha., this may be attributed to difference evaluation methods because they used electrochemical evaluation .

REFERENCES
1. Nyguen NT, Obturation of root canal system .In: Cohen S, Burns RC, editor. Pathway of the pulp.3.St.Louis: CV Mosby Co, 1984. 2. Figdor D, Apical periodontitis: a very prevalent problem. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002; 94(6): 6512.

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3. Saunders WP, Saunders EM, Assessment of leakage in the restored Pulp chamber of endodontically treated multi-rooted teeth. Int Endod J 1990; 23(1): 2833. 4. Mounce R, Glassman G, Bonded endodontic obturation: another quantum leap forward for endodontics. Oral Health 2004; 94(7):1316, 1922. 5. Shipper G, Trope M, In vitro microbial leakage of endodontically treated teeth using new and standard obturation techniques. J Endod 2004; 30:1548. 6. Hovland EJ, Dumsha TC, Leakage evaluation in vitro of the root canal sealer cements Sealapex. Int Endod J 1985; 18:17982. 7. Monticelli F, Sword J, Martin RL, Schuster GS, Weller RN, Ferrari M, Pashley DH, Tay FR, Sealing properties of two contemporary single-cone obturation systems. Int Endod J 2007; 40: 37485. 8. Al Hashimi MM. An evaluation of coronal microleakage in endodontically treated teeth using two different obturation techniques and two types of sealer at four different time periods. A thesis submitted to the College of Dentistry, University of Baghdad in partial fulfillment of the requirements for the degree of Master science in conservative dentistry, 2005. 9. Paqu F, Sirtes G. Apical sealing ability of resilon/Epiphany versus gutta-percha/AH plus: immediate and 16-months leakage. Int J Endod 2007; 40:722-9. 10. De Moor RJG, Martens LC. Apical microleakage after lateral condensation, hybrid gutta-percha condensation and soft core obturation: An in vitro evaluation. J Endod 1999; 15: 239-43. 11. Al-Hashimi MK. An in vivo evaluation of coronal microleakage in endodontically treated teeth. Iraqi Dent J 1997; 20: 59. 12. Pitts DL, Natkin E. Diagnosis and treatment of vertical root fracture. J Endod 1983; 9: 338-46. 13. Al- Bakri MM. A comparative study of apical microleakage by using different preparation and obturation techniques. A thesis submitted to the College of Dentistry, University of Baghdad in partial fulfillment of the requirements for the degree of Master science in conservative dentistry, 2009. 14. Clrak-Holke D, Drake D, Walton R, Rivera E, Guthmiller JM. Bacterial penetration through canals of endodontically treated teeth in the presence or absence of the smear layer. J dent 2003; 31:275-81. 15. Saatchi M, Rabie H, The apical sealing ability of AH26, AH Plus and ZOE root canal sealers. Dental Research Journal, 2005; 2. 16. Wu MK, Wesselink PR. Endodontic leakage studies reconsidered.Part I. Methodology, application and relevance. Int Endod 1993; 26:37-43. 17. Delivanis PD, Chapman KA. Comparison and reliability of techniques for measuring leakage and marginal penetration. Oral Surg Oral Med Oral Pathol 1982; 53: 4106. 18. Matloff I R, Jensen J R, Singer L. A comparison of methods used in root canal sealability studies. Oral Surg 1982; 53: 203-7. 19. Barthel CR, Moshonov J, Shuping G, rstavik D, Bacterial leakage versus dye leakage in obturated root canals. J Endod 1999; 32: 370-375. 20. Bergmans L, Moisiadis P, De Munck J, Van Meerbeek B, Lambrechts P, Effect of polymerization shrinkage on the sealing capacity of resin fillers for endodontic use. J Adhes Dent 2005; 7: 3219.

21. Schwartz R, Adhesive dentistry and endodontics: part 2bonding in the root canal system: the promise and the problemsa review. J Endod 2006; 32:112634. 22. Franklin Tay, Monoblocks in root canals: a hypothetical or a tangible goal. J Endod 2007; 33:391 7. 23. Bouillaguet S, Troesch S, Wataha JC, Krejci I, Meyer JM, Pashely D. Micro-tensile bond strength between adhesive cements and root canal dentin. Dent Master2003; 19:199-205. 24. Tay FR, Loushine RJ, Lambrechts P, Weller RN, Pashley DH. Geometric factors affecting dentin bonding in root canals: a theoretical modeling approach. J Endod 2005; 31:584-9. 25. Goracci C, Tavares AU, FabianelliA, et al, The adhesion between fiber posts and root canal walls: Comparison between Micro-tensile and push-out bond strength measurements. Eur J Oral Sci 2004; 112:35361. 26. Ferracane JL. Developing a more complete understanding of stresses produced in dental composites during polymerization. Dent Master 2005; 21:36-42. 27. Testarelli L, Milana V, Rizzo F, Gagliani M, Gambarini G, Sealing ability of a new carrier-based obturating material. Minerva Stomatol 2009; 58(5): 217-24. 28. Duggan D, Arnold RR, Teixeira FB, Caplan DJ, Tawil P, Periapical inflammation and bacterial penetration after coronalinoculation of dog roots filled with RealSeal 1 or Thermafil. J Endod 2009; 35: 852-7. 29. Feilzer AJ, de Gee AJ, Davidson CL, Setting stress in composite resin in relation to configuration of the restoration. J Dent Res 1987; 66:1636-9. 30. Alster D, Feilzer AJ, de Gee AJ, Davidson CL, Polymerization stress in thin resin composite layers as a function of layer thickness. Dent Master 1997; 13:146-50. 31. Santos J, Tjaderhane L, Ferraz C, Zaia A, Alves M, De Goes M and Carrilho M. Long term sealing ability of resin-based root canal fillings. Int Endod J 2010; 43:455-60. 32. Hammad M, Qualtrough A, Silikas N,Evaluation of root canal obturation: A three dimensional in vitro study. J Endod 2009; 35:541-4. 33. Kamran Gulsahi, Zafer C Cehreli ,Emel O Onay, Fugen Tasman-Dag, Mete Ungor,Comparison of the Area of Resin-based Sealer and Voids in Roots Obturated with Resilon and Gutta-Percha. . J Endod 2007; 33:1338 41. 34. Lumnije K, Peter S, Hans JG, AnjaBaraba, Ivica A, Ivana M, Active versus passive microleakage of Resilon/Epiphany and gutta-percha / AH plus. Aus Endod J 2010. 35. Wedding JR, Brown CE, Legan JJ, Moore BK, Vail MM. An in vitro comparison of microleakage between Resilon and gutta-percha with a fluid filtration model. J Endod 2007; 33:1447-9. 36. Chu CH, Lo ECM, Cheung GSP. Condensation Outcome of root canal treatment using Thermafil and cold lateral filling techniques. Int Endod J 2005; 38:179-85. 37. L e ona r d o, Ma r i a G, Silva, Effect of different rotary instrumentation techniques and thermoplastic filling on apical sealing. J Appl Oral Sci 2004; 12(1):89-92.

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38. Abarca AM, Bustos A, Navia M, A comparison of apical sealing and extrusion between Thermafil and lateral condensation techniques. J Endod 2001; 27(11): 670-2. 39. Gutmann Jl, Saunders UP, Saunders EM, An assessment of the plastic Thermafil obturation

technique .Part 2 Material adaptation and sealability. Int Endod J 1993; 26:179. 40. Inan U, Aydemir H, Tasdemir T. Leakage evaluation of three different root canal obturation techniques using electrochemical evaluation and dye penetration evaluation methods. Aust Endod J 2007; 33: 1822.

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The effect of two types

The effect of two types of disinfectant on shear bond strength, hardness, roughness of two types of soft liners
Rola W. Abdul-Razaq B.D.S., M.Sc. (1)

ABSTRACT
Background: Poor oral hygiene results in accumulation of dental plaque and dental biofilms, especially in elderly with denture, regular cleaning of the dentures using chemical or physical methods can minimize the risk of (stomatitis) in denture users. The aim of this study was to evaluate the effect of two types of disinfectant on some mechanical properties of two types of soft liners. Materials and methods: 180 specimens from 2 types of soft liners (Mollosile, Viscogel) were prepared and divided into 2 major groups, mollosile group, viscogel group for each test and each major group is divided into 3 subgroups, each subgroup includes 10 specimens. Hardness and roughness test specimens were consist of two discs, acrylic disc with dimensions(4mm,15mm)thickness, diameter respectively and soft liner disc with dimensions (2mm,15mm) thickness, diameter respectively. For shear bond test, specimens were prepared from two blocks of acrylic measuring (75mm, 25mm, 5mm)length, width, depth respectively with stopper (3mm) and handle of (13mm) thickness and soft liner material in the space between the two acrylic blocks. All specimens were stored in distilled water for 24 hours at 37Co then they were immersed into water(control group) , Solo, Chlorhexidine 0.2 % disinfectant (test groups) for 8 hours to simulate the weekly exposure time of soft liner with disinfectant. A profilometer device was used to measure the roughness property and Shore A for hardness property and Micro-computer controlled electronic universal testing machine for shear bond property. Results: The results revealed that there was a significant difference in roughness mean values for each soft liner after immersed in disinfectant solutions while there was no significant difference in mean values of (hardness, shear bond strength) for each soft liner after immersed into disinfectant solutions. Conclusion: Disinfectant solutions (SOLO, CHLORHEXIDINE) had no effect on hardness and shear bond strength of soft liners (MOLLOSILE, VISCOGEL) while they had effect on surface roughness by decreasing the surface roughness of these soft liners which is a favorable condition. Keywords: Soft liner, Disinfectant, Roughness, Hardness, Shear bond. (J Bagh Coll Dentistry 2012;24(2):27-31).

INTRODUCTION
The clinical use of soft denture lining materials was first reported in 1943(1).Soft lining materials are able to form an absorbing layer on the part of the denture in contact with oral mucosa and this allow less traumatic transmission of occlusal forces(2). The use of soft liners has become increasingly popular for providing comfort for denture wearers. Soft liners are often used for patients who cannot tolerate a conventional denture base (3). These materials have several disadvantages including color stability, resiliency, abrasion resistance, bond strength and porosity (4). The ideal hardness or softness for providing a greater comfort to the patient can be obtained with the use of soft materials, so hardness is important property for resilient material and should remain constant for a long period so that the material can efficiently fulfill their functions. Surface roughness is also important property; a rough surface can lead to biofilm accumulation and colonization of Candida albicans, which is the major etiological factor for denture-induced stomatitis .The denture made from two different materials can only be successful if there is an adequate bond between the materials (5), so the favorable properties of a denture liner in the absences of good adhesion to denture base
(1) Assistant lecturer, dep. of prosthetic dentistry, college of dentistry, Baghdad University.

materials are considered to be useless (6). Prosthesis have been identified as a source of cross contamination between patient and dental personal, so chemical disinfectant are a recommended method to prevent cross contamination when used after removal and before insertion of prosthesis into mouth (7). A denture disinfectant method should be effective for inactivation of microorganisms without adverse effects on the denture materials (8). The aim of this study was to investigate the effect of chemical disinfectant (solo, chlorhexidine 0.2%) on shear bond strength, hardness, surface roughness of two types of soft liners (mollosile, viscogel) .

MATERIALS AND METHODS


Totally 180 specimens were prepared from 2 types of soft liner (mollosile, viscogel) both of them are room temperature curing soft liner and 240 specimens of heat cure acrylic (Major dent, Italy) were prepared for surface roughness, hardness, shear bond tests. They were divided into 2 major groups (molosile , viscogel) group for each test, each major group includes 30 specimens and divided into 3 subgroups, each subgroup includes 10 specimens: Mw: mollosile specimens in water. Ms:mollosile specimens in solo.Mc: mollosile specimens in chlorhexidine.
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The same specimen groups for viscogel material. Surface roughness and Hardness test: The specimens of these tests consist of a disc of (15mm) in diameter and (4mm) in thickness of heat cure acrylic resin with (2mm) thick layer of the soft liner bonded to each disc. A brass pattern was constructed in a form of disc (15mm, 4mm) diameter, thickness respectively for preparation of acrylic disc and a silicone mould was prepared from which a wax patterns with dimensions of (15mm, 2mm) diameter, thickness respectively were produced. The disc of wax was placed on the disc of acrylic and both of them were invested as one piece inside the lower half of conventional dental processing flask that was filled with dental stone mixed according to the manufacturers instructions (dental stone Elite model, Italy) to prepare a mould for final specimens, a piece of glass was placed over the wax so the level of wax is with the level of stone and smooth surface of soft liner is created, after setting of stone, wax elimination was done and the mould was cleaned and left to dry then the soft liner was mixed according to the manufacturers instructions and applied into the mould by spatula, the flask was closed and pressure was applied by using hydraulic press up to 100 Kpa then the pressure was released and the flask was left for bench cure. After complete curing the specimens were removed and by using sharp knife the excess of material was removed after that the specimens were stored in distilled water for 24 hours at 37Co then they were immersed in disinfectant solutions (solo, chlorhexidine 0.2 %) for 8 hours to simulate the weekly exposure of soft liner with disinfectant(3). After that the specimens were removed and tested. A profilometer device was used to study the surface roughness property of each soft liner, and Shore A hardness tester was used to measure the indentation hardness of each soft liner. Shear bond strength test: The specimens of this test consist of 2-heat cure acrylic blocks with dimensions of (75mm, 25mm, 5mm) length, width, depth respectively with stopper of (3mm) and handle of (13mm) in thickness. A metal pattern was constructed with the same dimensions mentioned above to prepare acrylic specimens, each soft liner was mixed according to the manufacturers instructions and applied by spatula into the space between the two acrylic blocks, any excess of material was removed by using sharp knife and the specimen was put under weight (200)g for stability and left for bench cure, after complete curing the specimens were stored in distilled water for 24 hours at 37Co, then the specimens were immersed into disinfectant
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solutions (solo, chlorhexidine 0.2 %) for 8 hours to simulate the weekly exposure of soft liner with disinfectant(3). After that the specimens were tested for shear bond strength using Microcomputer controlled electronic universal testing machine and subjected to shear load with cross head speed (2mm/min) using load cell capacity (10 Kn), shear bond was calculated according to the following formula: Bond strength = F(n)/A(mm)2 (ASTM, specification D-638m, 1986).

RESULTS
Mw: mollosile specimens in water Ms: mollosile specimens in solo Mc: mollosile specimens in chlorhexidine Vw: viscogel specimens in water Vs: viscogel specimens in solo Vc: viscogel specimens in chlorhexidine. Roughness test: Table1: Descriptive statistics for surface roughness test in (m) for mollosile material. Group Sample No. Mean (m) S.D. 10 1.25000 0.55025 Mw 10 0.58000 0.15491 Ms 10 1.22000 0.50508 Mc Table 1 shows the mean values and the S.D. of surface roughness for mollosile material, the highest mean value was for water group and the lowest mean value was for solo group.

Table 2: Analysis of variance (ANOVA) test for surface roughness for mollosile material
Source Between groups Within groups d.f. 2 27 Mean square 1.432 7.38 0.193 0.0028 H.S FP-Value Value Sig.

P>.05(non-significant),p<.05(significant),p<.01(highly significant).

Table 3: L.S.D. test between control and test groups of mollosile material for surface roughness test
Groups mw*ms mw*mc ms*mc Difference between mean 0.67 0.03 0.64 L.S.D. 0.05 0.4041 Sig. H.S. N.S. H.S.

ANOVA test was described in table 2 which shows highly significant difference for mollosile material groups. L.S.D test in table 3 shows a

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highly significant difference for mw*ms and ms*mc while non significant difference for mw*mc.

Table 8: Descriptive statistics for hardness test for viscogel material


Group Sample No. Mean S.D. 10 41.6000 7.08989 vw 10 41.7000 3.49761 vs 10 41.8000 6.35609 vc

Table 4: Descriptive statistics for surface roughness test in (m) for viscogel material
Group Sample No. Mean (m) S.D. 10 2.89000 0.45570 Vw 10 2.63000 0.08232 Vs 10 0.86000 0.47187 Vc

Table 9: Analysis of variance (ANOVA) test for hardness for mollosile material
Source Between groups Within groups d.f. 2 27 Mean square 0.6333 0.26 2.4481 0.7739 N.S FP-Value Value Sig.

Table 4 shows the mean values and the S.D. of surface roughness for viscogel material, the highest mean value was for water group and the lowest mean value was for chlorhexidine group.

Table 5: Analysis of variance (ANOVA) test for surface roughness for viscogel material
Source Between groups Within groups d.f. 2 27 Mean square 12.202 83.8 0.1457 <.0001 H.S FP-Value Value Sig.

P>.05(non-significant),p<.05(significant),p<.01(highly significant).

Table 10: Analysis of variance (ANOVA) test for hardness for viscogel material
Source Between groups Within groups d.f. 2 27 Mean square 0.1000 0.00 34.300 0.9971 N.S FP-Value Value Sig.

P>.05(non-significant),p<.05(significant),p<.01(highly significant).

Table 6: L.S.D. test between control and test groups of viscogel material for surface roughness test.
Groups Difference L.S.D. Sig. between mean 0.05 0.26 N.S. vw*vs 2.03 0.3503 H.S. vw*vc 1.77 H.S. vs*vc

P>.05(non-significant),p<.05(significant),p<.01(highly significant).

ANOVA test was described in table 9,10 for mollosile and viscogel materials respectively shows non significant difference between control group and test group for both materials. Shear bond strength test: Table 11: Descriptive statistics for shear bond strength test in (N/mm2) for mollosile material Mean S.D. Group Sample No. N/mm2 10 0.09300 0.00483 mw 10 0.09700 0.00483 ms 10 0.09600 0.00516 mc

ANOVA test was described in table 5 which shows highly significant difference for viscogel material groups. L.S.D. test in table 6 shows highly significant difference for vw*vc and vs*vc while non significant difference for vw*vs. Hardness test: Table 7, 8 shows the mean values and S.D. of hardness test for mollosile and viscogel material respectively, in general the results for control and test group showed nearly the same mean values for both materials.

Table 12: Descriptive statistics for shear bond strength test in (N/mm2) for viscogel material
Group Sample No. mw ms mc 10 10 10 Mean S.D. N/mm2 0.06600 0.00516 0.06500 0.00527 0.06400 0.00516

Table 7: Descriptive statistics for hardness test for mollosile material


Group Sample No. Mean S.D. 10 26.3000 1.41813 mw 10 26.6000 1.71216 ms 10 26.8000 1.54919 mc

Table 11,12 shows the mean values and S.D. of shear bond strength for both mollosile and viscogel respectively, in general the results for control and test groups showed nearly the same mean values for both materials.
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Table 13: Analysis of variance (ANOVA) test for shear bond strength for mollosile material
Source Between groups Within groups d.f. 2 27 Mean square .00004 1.77 .00002 0.1891 N.S FP-Value Value Sig.

P>.05(non-significant),p<.05(significant),p<.01(highly significant).

Table 14: Analysis of variance (ANOVA) test for shear bond strength for viscogel material
Source Between groups Within groups d.f. 2 27 Mean square .00001 0.37 .00002 0.6943 N.S FP-Value Value Sig.

P>.05(non-significant),p<.05(significant),p<.01(highly significant).

ANOVA test was described in table 13,14 for mollosile and viscogel materials respectively shows a non significant difference between control group and test groups for both materials.

DISCUSSION
Although chemical denture cleanser have been considered to be efficacious method to prevent Candida albicans colonization and denture plaque formation (9), daily use of denture cleanser can affect the physical properties of denture acrylic resin bases and soft liners(10),because when immersed in soaking solutions or placed in oral cavity, soft liners undergo two processes, leaching out of plasticizers and other soluble materials and sorption of water or salivary components. So the fluctuation between these two processes affects the properties of denture liner material (11) . Aging or changes in physical properties of soft denture lining materials appear to depend upon their type or composition (12). Almost all soft liners became rougher to a greater or lesser extent by the immersion into denture cleansers. In this study mollosile material shows significant difference in surface roughness change which was decreasing in roughness when immersed in solo while viscogel material shows significant difference in surface roughness change which was decreasing in roughness when immersed in chlorhexidine. This decrease in roughness is favorable characteristic for soft liners because surface roughness is very important property of reline materials. This can be explained by, regarding the roughness of soft
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liners (Garcia et al,2003) stated that when these materials were immersed in cleansing products a loss of soluble components occurred leaving empty spaces or bubbles which is responsible for surface roughness, these bubbles or voids underwent an increase in size that resulted in crater, the limits of the craters are probably smaller when compared to the bubbles leaving specimens smoother and these differences between the two materials are attributed to the different chemical structure of the 2 soft liners (acrylic-base and silicone-base); therefore they have different properties and behaviors in the cleansers(14) , also changes of surface roughness of materials varied depending on both immersion time and types of cleansers. Hardness is one of the most challenging factors in the use of complete denture liners, the greater the softness, the greater the extension in absorbing the impact effect, thus less hardness is desirable characteristic for soft liners. In this study there is a non significant difference in hardness property for both materials when immersed in both types of disinfectant solutions, this results can be attributed to type of cleanser and type of soft liner because the type of denture cleansers are known to be important in assessment of the compatibility of cleansers with soft liners (15) this result agrees with(Azevedo et al, 2006) who found that there is no significant changes in hardness regardless of disinfectant solutions used, so it appeared that in this respect the materials were likely to be equally effective clinically. Bond strength property of reline materials are very important for their Cushioning effect which allow for more even distribution and maintenance of material shape, de-bonding results in unhygienic condition at the de-bonded region and causes functional failure of prosthesis(17) , both materials shows a non significant difference in shear bond strength when immersed in both disinfectant solutions, this can explain as, viscogel material is polymethyl/ethylmethacrylate and acrylic is polymethyle methacrylate , so according to (Garcia et al,2003) chemical adhesion may be explained by similar chemical composition of acrylic resin and resilient liners , so the shear bond was not affected by the immersion in disinfectant solutions. Mollosile material is silicone polymer based denture liner, the adhesion between mollosile and acrylic resin can be achieved by using an adhesive which is a solvent that dissolve the PMMA surface, however there is no chemical adhesion but the shear bond by using adhesive was not affected by the 2 types of disinfectant solutions which is attributed to the

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type of denture cleanser and type of soft liner and the compatibility between them as mentioned before the type of denture cleanser is important in assessment of the compatibility of cleanser with soft liner, also changes in physical properties of soft liner depend upon their type and composition.

REFERENCES
1. Tylman S. The use of elastic and resilient synthetic resins and their copolymer in oral, dental and facial prosthesis. Dental Digest 1943; 49: 167. 2. Brozek R, Koczorowski R, Rogalewice R, Voelkel A, Czarnecka B, Nicholson JW. Effect of denture cleansers on chemical and mechanical behavior of selected soft lining materials. Dent Mater J 2011;27(3):281-90.(IVL) 3. Sarac D, Sarac YS, Kurt M, Yuzbasioglu E. The effectiveness of denture cleansers on soft liners colored by food colorant solutions. J Prosthodont 2007; 16(3): 185-91. 4. Anusavice KJ. PhillipsScience of dental materials 11th ed. Philadelphia: Saunders; 2003. p. 269-71. 5. Segundo ALM, Pisani MX, Paranhos HFO, Souza RF, Lovato CHS. Effect of a denture cleanser on hardness, roughness and tensile bond strength of denture liners. Braz J Oral Sci 2008; 7(26): 1596-601. 6. Mese A, Guzel KG, Uysal E. Effect of storage duration on tensile bond strength of acrylic or siliconebased soft denture liners to a processed denture base polymer. Acta Odontal Scand 2005; 63: 31-5. 7. Hamouda IM, Ahmed SA. Effect of microwave disinfectant on mechanical properties of denture base acrylic resin. J Mechnical Behavior of Biomedical Materials 2010; 05: 002. 8. Machado AL, Breeding LC, Vergani CE, Prerez LEDC. Hardness and surface roughness of reline and denture base acrylic resins after repeated disinfection procedures. J Prosthet Dent 2009; 102(2): 115-22. 9. Nikawa H, Ntshlmura H, Yamamoto T, Hamada T, Samaranayakl LP. The role of saliva and serum in Candida albicans biofilm formation on denture acrylic surface. Microbial Ecology in Health and Disease, 9:35. 10. Nikawa H, Iwanaga H, Hamada T, Yuiita S. Effect of denture cleansers on direct soft denture lining materials. J Prosthet Dent 1994(a); 72: 657. 11. Sinobad D, Murphy WM, Hugget R, Brooks S. Bond strength and rupture properties of soft denture liners. J Oral Rehabil 1992; 19: 151-60. 12. Wagner WC, Kawano F, Dootz ER, Koran A. Dynamic viscoelastic properties of processed soft denture liners part I. J Prosthet Dent 1995(a); 73: 471.

13. Garcia RM, Leon BT, Oliveira VB, Del Bel Cury AA. Effect of a denture cleanser on weight, surface roughness and tensile bond strength of two resilient denture liners. J Prosthet Dent 2003; 89: 489-94. 14. Abdul-Kareem AA. Effect of denture cleansers on sorption, solubility, tensile bond strength and surface roughness of two soft denture lining materials. A master thesis, Prosthetic Department, University of Baghdad 2006. 15. Jin C, Nikawa H, Makihira S, Hamada T, Furukawa M, Murata H. Changes in surface roughness and color stability of soft denture lining materials caused by denture cleansers. J Oral Rehabil 2003; 30: 125-30. 16. Azevedo A, Machado AL, Vergani CE, Giampaolo ET, Parvarina AC, Magnani R. Effect of disinfectants on hardness and roughness of reline acrylic resins. J Prosthodont 2006; 15(4): 235-42. 17. Kawano F, Dootz ER, Koran A, Craig RG. Comparison of bond strength of six soft denture liners to denture base resin. J Prosthet Dent 1992; 68: 36871.

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Immunohistochemical detection

Immunohistochemical detection to evaluate the biological role of Ti implants coated by a combination of fibronectin protein and hydroxyapitate (EPD) (in vivo study)
Athraa Y.Al-Hijazi, B.D.S., M.Sc., Ph.D. (1) Thair L-Al-Zubaydi, M.Sc., Ph.D. (2) Eman I. Mahdi, B.D.S., M.Sc. (3)

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

INTRODUCTION
The clinical success of dental implants is directed by implant surface and bone cell responses that promote rapid osseointegration and long-term stability Several surface modification have been proposed in order to promote osseointegration of titanium implants Hydroxyapatite (HA) is one of the most extensively used synthetic calcium phosphates for bone replacement and in dental field because of its chemical similarities to the inorganic Hydroxyaptite component of bone and teeth coated titanium implant have been becoming more popularly because long-term good clinical results and the quick new bone formation around the implant of implantation occurs. These coating have been found to accelerate intial stabilization of implants by enhancing bony ingrowth and stimulating osseuos apposition to the promoting a rapid fixation of the devices to the skeleton
(1) Professor, Oral Histology& Biology, College of Dentistry. (2) Senior Scientific Researcher, Ministry of Science Technology, Baghdad, Iraq. (3) Assistant Professor, Oral Histology & Biology, College of Dentistry.

Fibronectin is a large adhesive glycoprotein highmolecular weight extracellular matrix involved in many cellular processes, including tissue repair, embryogenesis, blood-clotting,cell migration/ adhesion growth and wound healing. Coating of dental implant with FN enhanced osteoblast differentiation and increases the rate of bone formation at the site of implantation Osteocalcin is a bone specific non-collagenous protein. Osteocalcin is synthesized by osteoblst during bone formation and deposited mainly in the extracellular matrix It is consider as aspesific marker of osteoblast cells because osteocalcin is involved in the process of osteoid minerlization, the protein is expressed mainly during phase of bone formation Growth hormone receptor (GHR) is a transmembrane receptor for growth hormone. Binding of GH to GHR promotes receptor dimerization and initiates a cascade of events leading to protein phosohorylation and activation of nuclear protein and transcription factors in osteoblasts GH has an effect on the proporations of hematopoietic and mesenchymal progenitor cells in the bone
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marrow, and that GH is essential for both the induction and later progression of osteogenesis

accordance with the manufacture instruction (Abcam UK).

MATERIALS AND METHODS


Materials CpTi readymade implants from friatic company were modified and machined in diameter about 3.5mm, length of 8 mm (5mm was threaded and 3mm was flat). Fibronectin protein (Applied by Biosystem, CA, U.S.A). Hydroxyapatite powder (Merck, Germany). -Ethanol 99.8% (GFs chemicals, Germany). -Hydrogen peroxide black -Protein black. -Biotinylated goat anti-mous IgG -Streptavidin peroxidase -DAB chormogen -Monoclonal antibodies were used in the present study (OC4-30, ab13418)(MAB 263,ab 11380) respectively. -Abcam anti mouse HRP/DAB detection kit (ab64259-15). Methods Electrophoretic EPD coating was applied on dental implants suspension for HA was prepared by adding HA powder to the solvent which was ethanol 100g/liber in a baker under continous stirring .sixteen (16) Newzeland rabbits aged (1012 months) were used in this study they were divided into four groups for (3days 1,2 and 6 weeks) healing intervals (4) animals for each period. Animals were generally aneasthesised and atramatic surgical technique was performed to prepare two holes in the tibia FN coated implant was inserted in one hole and uncoated implant (control) placed in the second one. In the left tibia HA coated implant was inserted in one hole and uncoated implant placed in the second one. Animals we sacrificed after 3ays 1,2 and 6 weeks. Immunehistochemical examination(IHC) All tissue specimen samples and controls, were fixed in 10% neutral formation and processed in a routin paraffin blocks. Each formalin-fixed-paraffin-embedded specimen had serial section were prepared as follows: 5m thickness sections were mounted on clean glass slides for routine haematoxylin and Eosin staining (H&E), from each block of the studied sample and the control group for histopathological reexamination. Other 4 sections of 5m thickness were mounted on positively charged microscopic slides to obtain a greater tissue adherence for immunohistochemistry. The procedure of the IHC assay adapted by this study was carried out in
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RESULTS
The result in this study show a significant higher torque was needed to remove implant electrophoreticall coated with HA and with fibronectin protein (HEF) in (15.31N.cm, 30.28 N.cm) 2 and 6 weeks of implantation respectively than the uncoated implants. all values were increasing with advancing time and significant differences between different time periods was present, P0.000(table1). Radiolgraphical evaluation revealed cortical bone thickness with clear radioopacity around the coated implant (Figure 1). Immunohistochemical examination for osteocalcin expression of implant in different interval periods. Titanium implant coated with fibronectin protein and HA shows strong positive immunohistochemical localization of osteocalcin and many progenitor cells are present nearby which shows positive reaction to osteocalcin at the site of implant of 3 days duration (Figure 2,3). In one week duration, moderate positive immunohistochemical localization of osteocalcin protein in rabbit tibia in implant coated with HA and fibronectin protein is illustrated. Woven bone formation with positively stained osteoblast cell neucli, active fibroblast cells and in the extracellular matrix of woven bone (Figure 4). At 2 weeks duration section of implant coated with HA and fibronectin protein shows numerous bone trabeculae within active woven bone, stain negatively as shown blue coloure with counter haematoxyline stain while formative cells shows positive stain (Figure 5). The high power view shows positive stain for the progenitor cell (Figure 6). Threads of Ti implant coated with HA&FN for 6weeks duration shows positive DAB stain in osteoblast cell for osteocalcin (Figure 7). Immunohistochemical examination for growth hormone receptor expression of implant in different interval periods. Primitive bone formation around fibronectin coated implant of three days duration of implantation and strong positive immunohistchemical stain for GHR is seen in progenitor cells and reticular cells (Figure 8). Bone section at implant coated with HA and fibronectin protein for 1 week duration shows area of woven bone tissue strong positive localization of GHR in progenitor osteoblast cell and in extracellular matrix (Figure 9).

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Bone trabeculae with active primitive bone formation in titanium implant coated with HA and fibronectin protein for 2 weeks duration marrow tissue of different sizes showing positive stain are enclosed by anastemosing trabeculae, osteoblast seen at the peripharyes and huge neumerous of osteocytes are located within bone matrix , both types of cells show positive stain, the trabeculae of bone itself are stained negatively (Figure10). After six weeks of implantation mature lamellated bone is deposited at implant site, it shows negative DAB stain for GHR, some osteocytes are embedded within bone matrix osteon canal and in endostium area stain positively (Figure 11).

DISCUSSION
In this study we use biological organic material represented by fibronectin coated the implant and others used in combination with HA. The general histologic finding abserved that all surface investigated were biocompatible and osseoconductive. Fibronectin protein is biological glycoprotein act as osseoinductive material, it enhance recruitment of progenitor cell to its area and activate its differentiation into osteoblast cells once these cells deposit organic matrix specially collagen fiber, the FN will facilitate the adherence of these cells to fiber, these biological sequence facilitate and accelerate bone formation process Modification effect of HA in coating process that enhance progenitor cell to differentiate to fibroblast in addition to osteoblast and also reticular cell activation which showed reticular fiber deposition when needs for more investigation These results indicating that active bone apposition with strong attachment was achieved on the surface of implant coated with HA and FN protein which may be the reason for higher removal torque value. The possible explination for these finding is that surface chemistry is effectively influenced osseointegration and the higher torque value may be interpreted as an increase in the strength of bony integration at the bone, implant interface. This is in agreement within work of Suh et al The radiographic examination shows increase in the thickness of cortical bone at experimental implant sites indicating increased bone formation and maturation around the coated implants for the six weeks duration of implantation. In studied groups of the present study, following insertion of a biocompatible CpTi implant into cortical bone the implants were not submitted to any load, in most of the implants the presence of such
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thickening (corticalization process was observed, despite the non-functioning of these implants in agreement with the finding of Hammad et al It may be suggested that this bone response constitutes just a step in the entire bone healing process even in the absence of load. Immunohistochemical findings, osteocalcin of that Osteocalcin are positively expressed in both coated and uncoated implants and for all coating material in different intervals period. Bone marrow tissue is positively stained indicating osteocalcin protein localization. Strong positive expression of osteocalcin was noted with agroup of implant coated with FN and also coated with HA (HEF). This is in agreement with (5) Timothy et al and Tardieu (10) they revealed that coating of implant with FN protein enhanced osteoblastic differentiation and minerlization in bone marrow stromal cell, also FN. Protein function to stimulate bone formation by moving adult stem cells from a site far away from the surrounding of the implant into the implanted site by chemotaxis so as to differentiation into osteoblasts .In 6 weeks duration, osteocalcin shows negative immunohistochemical stain for localization of , osteocalcin but it shows positive expression on osteoblast lining the surface of osteon and when there is area of bone formation. These findings are in agreement with Muramatsu et al, 2005 study which indicated that agreater osteocalcin expression is observed at 14 and 21 days characterization the periods when intense minerlization of the bone tissue occurs during alveolar bone healing process. In this study GHR shows positive expression in coated and uncoated implants in all healing interval periods. In two week duration osteoid tissue formed around titanium implant shows positive localization of GHR in the formative cell progenitor that are irregularly arranged within primitive bone formed. After 6 weeks of implantation osteon canal and in endostium area shows positive localization of GHR. The differences in the bone reaction between coated and uncoated implants not only suggesting a high osteoconductive potential of the coated material but also its osteoinductivity, the osteoconductive action was seen in all coated groups specially for that coated with mixing of FN and HA where bioactive properties can be seen by the presence of fibrovascular tissue, osteoblast activity and expression of bone marker new bone formation, these finding was in agreement with Al-Mudarris et al (16) and Hammad et al (17)

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REFERANCE
1. Lee JH, Nam H, Ryu HS, Seo JH, Chang Bs, Lee CK. Bioactive ceramic coatings of cancellous screws improves the osseointegration in the cancellous bone. J Orthop Sci 2011; 16:291-7. 2. Xiao SJ, Kenausis G, Textor M. Biochemical modification of titanium surfaces. In: Berunette DM, Tengvall P, Textor M, Thomsen P, editor. Titanium in medicin. Berlin : Spreingler Verlay, 2001;417-53. 3. Hung J, Li X, Koller GP,. Silvio LD. Electrohyrodynamic deposition of nan-titanium doped hydroxyapatite coating for medical and dental application. J Mater Sci Mater Med 2011; 22:441-496. 4. Obadia L, Jullien M, Quillards, Rouillion T, Pilet P, Guicheux J, Bujoli B, Bouler JM. Na-doped tricalcium phosphate: physic chemical and in vitro biological properties. J Mater Sci Mater Med 2011;22:593-600. 5. Timothy AP, Catherine DR, Kellie LB, Andress JG. Simple application of fibronectin- mimetic coating enhances osseointegration of titanium implants. J cell Mol Md 2009; 13(8B):2602-12. 6. Caoa T, Henga BC, Yea CP, Liua H, Toha WS, Robsonb P, Lib P, Hong YH. Osteogenic differentiation within intact human embryoid bodies result in a marked increase in osteocalcin secretion after 12 days of in vitro culture, and formation of morphologically distinct nodule-like structures Tissue and Cell 2008; 37(4): 325-34. 7. Lee NK, Sowa H, Hinoi E, Ferron M, Ahn JD, Confavreux C, Dacquin R, Mee PJ, McKee MD, Jung DY, Zhang Z, Kim JK, Mauvais-Jarvis F, Ducy P, Karsenty G. Endocrine regulation of energy metabolism by the skeleton. Cell 2007; 130 (3): 456 69. 8. Cool SM, Grunert M, Jackson R, Li H, Nurcombe V, Wters MJ. Role of growth hormone receptor signaling on osteogenesis from murine bone marrow progenitor cells. Biochem Biophys Res Commun 2005; 16:338(2):1048-58 9. Jennifer E. Rowland, Agnieszka M. Lichanska, Linda M. Kerr, White M, Elisabetta M. dAniello. ,Maher SM, Brown R, Teasdale RD,Noakes PG. Waters :In Vivo Analysis of Growth Hormone Receptor 10.

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Signaling Domains and Their Associated Transcripts Molecular and Cellular Biology, 2005; 25(1): 66-77 . Maher SM, Brown R, Teasdale RD,Noakes PG. Waters. In Vivo Analysis of Growth Hormone Receptor Signaling Domains and Their Associated Transcripts. Molecular and Cellular Biology 2005; 25(1): 66-77 . Tardieu P. Process for the preparation of protein mediated calcium hydroxyapitite (HAP) coating on metal substrate. Patent application number 12/175812 Assignee council of scientific and industrial research Internationalclasses: A61L 27/32:A61L27/00 2010. Jimbo R, Coelho PG, Vandeweghe S, Schwartz-Fiho HO, Hagashi M, one D, Andersson M, Wennerberg A. Histological and three-dimensional evaluation of osseointegration to nano structured calcium phosphate-coated implants. Acta Biomater 2011;21:20-5. Suh JY Jeung OY, Chio BJ, Park JW. Effects of a novel calcium titanate coating on the osseointgration of blasted endosseous implantatsin rabbit tibiae. ClinOral Implant Res 2007; 17:362-4. Januario AL, Sallum EA, Toledo S, Sallum AW, Nocitif HJ. Effect of Calcitonin on Bone Formation Around Titanium Implant. A histometric study in rabbits. Braz Dent J 2001;12(3):158-62 Hammed TI, Al-Ameer S.S, Al-Zubaydi TL. Histological and mechanical evaluation of electrophoretic bioceramic deposition on Ti 6AL-7Nb dental implants. A phD thesis, College of Dentistry, University of Baghdad 2007. MuramatsuT, Hamano H, Ogami K, Ohta K, Inoue T, Shimono M,Reduction of osteocalcin expression in aged human dental pulp. National Library of Medicine 2005;38 (11):817-21. AL-Mudarris BA, Salem SAL, Al-Zubaydi TL. The significance of biometric calcium phosphate coating on commercially pure titanium and Ti-6AL-7Nb Alloy.A phD thesis, College of Dentistry University of Baghdad 2006. Hammed TI, Al-Ameer S.S, Al-Zubaydi TL. Histological and mechanical evaluation of electrophoretic bioceramic deposition on Ti 6AL-7Nb dental implants. A PhD thesis, College of Dentistry, University of Baghdad 2007.

Table 1: Summary Statistics for Removal Torque test in different studied and suggested of coated materials treated along two weeks and six weeks measured continuously
Torque- test Period After (2) weeks After (6) weeks Material FN+HA (HEF) FN+HA (HEF) Groups R - Control L1 - Coated R - Control L2 - Coated N 4 4 4 4 Mean 11.11 15.31 18.28 30.28 S.D. 1.38 1.20 0.60 0.76 S.E. 0.69 0.60 0.30 0.38 95% Confidence Interval for Mean Lower Bound Upper Bound 8.91 13.30 13.41 17.22 17.33 29.07 19.23 31.49 Min. 10.00 14.38 17.50 29.38 Max. 13.13 16.88 18.75 31.13

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Figure 1: Conventional radiographic view for Ti implant coated with HA and fibronectin protein for 6 weeks shows overhang bone on the implant. Where (C) uncoated and (HEF) coated with fibronectin protein and hydroxyapatite.

Figure 2: Positive DAB stain immunohistochemical localization of osteocalcin protein in site surface of titanium implant coated with FN and HA in rabbit tibia for 3 days duration DAB with haematoxylin counter stain x 100

Figure 3: High power view of previous Figure 2 shows positive brown colour for DAB stain for stromal cells to osteocalcin protein DAB with haematoxylin counter Stain x 200.

Figure 4: View for positive immunohistochemical localization of osteocalcin protein in nucleous of osteoblast active fibroblast cells and in the extracellular matrix of woven bone deposite around the titanium implant coated with FN and HA for 1 week duration in rabbit tibia.DAB with haematoxylin counter stain x 200.

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Figure 5: Immunohistochemical view for localization of osteocalcin protein in titanium implant coated with FN and HA for 2 weeks duration shows negative stain to calcified bone trabeculae as shown blue stain) and only the formative cells shows positive stain.DAB with haematoxylin counter stain x 400.

Figure 6: High magnification view of previous Figure 2 shows bone trabeculae (negative stain) and the formation and progenitor between shows positive stain DAB with haematoxylin counter stain x 400

Figure 7: Immunohistochemical view of threads of Ti implant coated with HA and FN for 6 weeks duration shows positive DAB stain in osteoblast cells for osteocalcin protein as it occupies the surface lining the bone DAB with haemtoxylin counter stain X200.

Figure 8: View for positive immunohistochemical DAB stain for GHR in titanium implant surface coated with HA and FN for 3 days duration. DAB with haematoxylin counter stain x 200

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Figure 9: Woven bone view of titanium implant coated with HA and FN for 1 week duration shows positive DAB stain for GHR localized extracellular matrix and in progenitor osteoblast DAB with haematoxylin counter stain x 400.

Figure 10: Bone trabeculae view of titanium implant coated with HA and FN for 2 weeks duration shows positive DAB stain for GHR localized only on osteocyte and osteoblast , while bone itself shows negative stain note the huge numerous number of osteocyte DAB with haematoxylin counter stain x 200

Figure 11: Thread view of titanium implant coated with HA an FN for 6 weeks duration shows negative stain for GHR in mature bone and only positive in the area occupied by osteon canal and in endostium area DAB with haematoxylin counter stain x 200.

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Evaluation of 900 mhz mobile phone effects on palate and tooth germ development in mouse embryo (histological & immunohistochemical study)
Faten H. Berto, B.D.S. (1) Athraa Y. Al-Hijazi, B.D.S., M.Sc., Ph.D. (2)

ABSTRACT
Background Mobile telephones, sometimes called cellular phones (GSM, Global System for Mobile Communication) or handies, are now an integral part of modern telecommunications. In some parts of the world, they are the most reliable or only phones available. In others, mobile phones are very popular because they allow people to maintain continuous communication without hampering freedom of movement.This study was carried out to evaluate the effects of 900 MHz mobile phone on palate and tooth germ development in mouse embryo for the period of (16th day, 18th day intrauterine life and one day postnatal life). Materials and Methods Thirty pregnant Bulb-c Albeno Swiss female mouse (2-3 months of age, 100-125 gm of weight), were used in the present experiment. Those mice were divided into three groups. The first group consisted of 6 pregnant mice were assigned as a control group. The second group consisted of 12 pregnant mice were exposed to mobile phone radiation for 60 minutes daily and the third group consisted of 12 pregnant mice were exposed to mobile phone radiation for 120 minutes daily starting from the zero day of gestation till the day of scarification. The embryos of mice; were obtained at different period of gestation (At 16th day I.U.L., 18th day I.U.L.,and One day old postnatal period). Results Histological examination and immunohistochemical evaluation for CD34 expression were done for all animals including control group showed that mobile phone (EMF radiation) with 900 MHz in short exposed period (one hour) can stimulate tooth germ cells as it was shown,an early appearance of tooth germ in cap stage at 16th day I.U.L and positive expression of CD34 marker on dental tissue. Conclusion In this study we investigated an important point that the effects of mobile phones concerned on mesenchymal germ cell rather than ectodermal germ cell which represented by positive reaction of CD34 on mesenchymal cell of dental sac ,bone and cartilage. Increment in time exposure to EMF radiation emitted from mobile phone for 2 hours duration showed retardation in tooth development with obvious reduction in size of the mice. Key words: Radiofrequency radiation, tooth germ, mobile phone. (J Bagh Coll Dentistry 2012;24(2):39-46).

INTRODUCTION
Radiofrequency fields are part of electromagnetic spectrum. For the purpose of international electromagnetic fields (EMF) project. Such fields are defined as those within the frequency range (10MHz-3000MHz). Common sources of radiofrequency fields include: mobile telephones, television broadcast, microwave ovens, medical diathermy, radar, satellite links, microwave communications and sun (1). Mobile phone, some time called cellular phone (GMS, Global system for mobile communication), mobile telecommunication system has been widely used all over the world. In others, mobile phones are very popular because they allow people to maintain continuous communication without hampering freedom of movement (2). Cell phones operate within the frequency band of 800 MHz, 900 MHz and 1800 MHz and the latest 3G technology works between 1900 -2200 MHz Over the past two decades, mobile telecommunication system has been widely used all over the world.
(1) MSc. Student, Department of Diagnosis, College of Dentistry, University of Baghdad. (2) Professor, Department of oral Diagnosis, College of Dentistry, University of Baghdad.

Mobile or cellular phones are now an integral part of modern telecommunications. In many countries, over half the population use mobile phones and the market is growing rapidly. At the end of 2009, there were an estimated 4.6 billion subscriptions globally. In some parts of the world, mobile phones are the most reliable or the only phones available. Mobile phones communicate by transmitting radio waves through a network of fixed antennas called base stations. Radiofrequency waves are electromagnetic fields, and unlike ionizing radiation such as X-rays or gamma rays, can neither break chemical bonds nor cause ionization in the human body. Widespread concerns have been raised about the possibility that exposure to the radiofrequency (RF) fields from mobile telephones or their base stations could affect peoples health Various epidemiological and experimental studies have been carried out and the results have shown to have a close relation between biological effects and Electromagnetic radiation (3). A large number of studies have been performed over the last two decades to assess whether mobile phones pose a potential health risk. To date, no adverse health effects have been established as being caused by
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mobile phone use. Although there is a vast body of material on the biological effects of radiofrequency fields, current risk assessment is still limited. There are several hypotheses and results of biological effects such as thermal effects, genetic and carcinogenetic effects and cancers related investigations. The use of mobile phones operating in the 900MHz frequency band is very widespread and ever increasing (4). Tissue heating is the principal mechanism of interaction between radiofrequency energy and the human body. At the frequencies used by mobile phones, most of the energy is absorbed by the skin and other superficial tissues, resulting in negligible temperature rise in the brain or any other organs of the body. A number of studies have investigated the effects of radiofrequency fields on brain electrical activity, cognitive function, sleep, heart rate and blood pressure in volunteers. To date, research does not suggest any consistent evidence of adverse health effects from exposure to radiofrequency fields at levels below those that cause tissue heating. Further, research has not been able to provide support for a causal relationship between exposure to electromagnetic fields and self-reported symptoms, or electromagnetic hypersensitivity (5). Concern has been expressed for number of years that exposure to radiofrequency (RF) fields emanating from mobile phones and radar and television transmitters may increase the incidence of cancer in humans (6). Epidemiological studies have not indicated an increased cancer risk, but the methodology and exposure assessment are generally considered to have been suboptimal. Several reports have indicated that electromagnetic fields (EMF) enhance free radical activity in cells. Free radicals kill cells by damaging macromolecules, such as DNA, protein and membrane (7). Tooth development or odontogenesis is the complex process by which teeth form from embryonic cells, grow, and erupt into the mouth. Although many diverse species have teeth, nonhuman tooth development is largely the same as in humans. The tooth bud (sometimes called the tooth germ) is an aggregation of cells that eventually forms a tooth. These cells are derived from the ectoderm of the first branchial arch and the ectomesenchyme of the neural crest. The tooth bud is organized into three parts: the enamel organ, the dental papilla and the dental follicle (8). The palate has two key stages of development during embryonic (primary) and an early fetal (secondary) involving the fusion of structures and a key epithelial to mesenchymal transition (9). The primary palate is formed by two parts: maxillary
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components (lateral) &frontonasal prominence (midline). The secondary palate can also be divided in two anatomical parts: Anterior hard palate &Posterior soft palate. The oral side of the palate is covered with a squamous stratified epithelium. The surface of the hard palate of most mammalian species is further thrown into a series of palatal ridges or rugae palatinae that are transversal ridges. (10). Oral tissues are one of the important parts of head/body that absorbs the radiation emitted from mobile phones, there were a lot of studies in that the effects of mobile phones on head were investigated; but did not encounter any histological study focused on the effects on tooth development. Therefore, the goal of this study is to investigate and to research an answer to the question of have mobile phones effects on palate and tooth germ development.

MATERIALS AND METHODS


Handsets of global system for communication (GSM) mobile phone of the same brand and model were used (Nokia 1100). Thirty pregnant Bulb-c Albeno Swiss female mouse (2-3 months of age, 100-125 gm of weight), were obtained from the animal house of the national center for drugs control and research, used in the present experiment. The pregnant female was separated from male in a different special Plexiglas cages surrounded by the edges of the aluminum (Width 15 cm and height 10 cm); food pellets, bedding and environmental conditions (temperature, humidity and ventilation) were equal among all animals. Those mice were divided into three groups. The first group consisted of 6 pregnant mice were assigned as a control group, nothing applied to mice in this group and they completed their life cycle in the cage during the study period. The second group consisted of 12 pregnant mice were exposed to mobile phone radiation for 60 minutes daily and the third group consisted of 12 pregnant mice were exposed to mobile phone radiation for 120 minutes daily starting from the zero day of gestation till the last day of scarification .The embryos of mice; were obtained at different period of gestation (At 16th day I.U.L., 18th day I.U.L., and One day old postnatal period). Histological preparation: Sagittal sections through the head of the embryos were separated from the body and preserved in 10% buffed formalin for 72 hours for histological examination. The specimens were washed well in running water, then dehydrated through graded series of alcohols (50, 60, and 70 up to absolute alcohol then xyline), cleared and embedded in paraffin wax. Serial sections of specimens were put at 5 microns by Reichert Jung Microtome,

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and stained with Hematoxylin and eosin .All sections were examined under light microscope. Immunohistochemistry: This study was performed on all formaline fixed paraffin embedded blocks for all control and experimental groups of different coating materials and techniques using CD34 with Imunohistochemistry Detection Kit, HRP, Mouse primaries (mouse tissue), BioAssayTM.

Figure 4: distribution of CD34 marker in the progenitor cell and blood vessel (arrow) in primitive mouth cavity.AEC stain X100
B-Experimental group 1: Histological feature for upper and lower jaw showed tooth germ cap to bell stage .Complete fusion of secondary palate but still nasal septum not fused with it, and tongue is high in position filled the oronasal space. Lower tooth germ illustrate stage (cap to bell) in development and showed enamel organ with 4 layers inner enamel epithelia ,outer enamel epithelia ,stellate reticulum ,stratum intermedium ,dental papilla, and dental sac (Figure 5). Positive expression of CD34 was illustrated in dental sac, in mesenchymal cell while negative expression was reported in enamel organ cell (Figure 6).

RESULTS
Clinical findings A- In the present study the pregnant mice which were exposed to EMF radiation of mobile phone for a period of 2 hours, showed a retardation in delivery time as for control group, pregnant mice deliver embryo at 20-21 days of gestation period, while experimental group which were exposed for 2 hours showed to be delivered in 28-30 days. B-Clinical observation also illustrates different in the size of the embryos .Control group and experimental group one showed to be approximately the same, their size range from (14-16 mm3) in 18th day, while experimental group two records (6-8mm3).One day old mice for control and experimental group one, their size range from (40-50 mm3), while for experimental group two (30-35 mm3). Histological and immunohistological findings At 16th day I.U.L. A-Control group: Histological sections of the embryo head showed upper tooth germ to be in bud stage represented basal cell and central polyhedral cells (figure 3). CD34 expression was detected in the progenitor cell in primitive mouth cavity of the mice (Figure 4).

Figure 5: lower tooth germ at cap to bell stage.H&EX200

Figure 6: positive reaction of CD34 in dental sac (DS).AEC stain X200 Figure 3: upper tooth germ in bud stage showed: basal cell (BC), central cell polyhedral in shape (arrow), dental lamina (DL).H&EX200
C-Experimental group2: A histological finding recorded a primitive mouth cavity thickening in oral epithelia, underneath it ectomesen-chymal tissue. Fig (7).Negative expression of CD34 marker detected on cells of oral epithelia and ectomesenchymal cells. (Figure 8).

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Figure 7: primitive mouth cavity of embryo mouse 16th day intrauterine .H&E X200.

B-Experimental group 1: Histological findings illustrate tooth germ at advance bell stage with apposition of dentin. Numerous blood vessels detected in the dental pulp. Figure(11). Positive expression of CD34 was localized in dental papilla and dental sac and in area of cell bone formation, while negative AEC stain detected in enamel organ (Figure 12).

Figure 8: Negative immunohistochemical expression for CD34 on cells of oral epithelium (OEP), and ectomesenchymal cell (EMC).AEC X400
At 18th day I.U.L A-Control group: Histological section showed tooth germ at bell stage for the lower jaw and tooth germ in cap stage for the upper. Differentiation of dental papilla to odontoblast cell can be detected but with no feature of apposition of dentin (Figure 9). Immunohistochemical reaction for localization of CD34 in tooth germ shows moderate positive reaction in dental sac and weak position in dental papilla (Figure 10).

Figure 11: tooth germ showed odontoblast (OD), dentin (D) and preameloblast (PAB).H&EX200

Figure 12: positive reaction for CD34 localized in dental pulp (DP) and in dental sac (DS) around.AECX200
C-Experimental group 2: This group illustrated tooth germ in bud stage in upper jaw and disturbed and displacement in cells of basal layer and central layer. While lower tooth germ showed tooth development in cap stage also displacement and disturbances in the cell micro architecture were reported in figures 13. Negative expression of CD34 was illustrated in all dental layers of tooth germ except demarked line of basement membrane showed positive stain (Figure 14).

Figure 9: upper tooth germ in cap to bell stage showed dental papilla (DP), inner enamel epithelia (IEE), and dental lamina (DL).H&E X100

Figure 10: Immunohistochemical reaction for localization of CD34 in tooth germ showed positive reaction in dental sac area (arrow),and weak positive reaction in dental papilla(DP).AEC X200

Figure 13: Cross section in primitive mouth showed dental lamina (DL), enamel organ (EO), sign of displacement (arrow).H&EX200

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Figure 14: color demarked basement membrane(arrow).AEC stain X400


At one day old (postnatal life) A-Control group: Histological examination for all sections illustrated upper tooth germ at early bell stage and lower tooth germ at advance bell stage (Figure 15). Immunohistochemical view for the tooth germ illustrated negative reaction for CD34 in enamel organ and positive reaction in dental sac and endothelial cell of arteriol (Figures 16 A &B).

Figure 17: tooth germ .Showed odontoblast (OD), dentin (D), enamel (E) and ameloblast (AB).H&EX400

Figure 18: positive reaction for CD34 in Dental sac (DS), blood vessels showed strong positive reaction stain (arrow) ,upper limit of the figure showed negative stain (blue)for enamel organ(EO).AEC stain X400
C-Experimental group 2: Histological findings illustrateed tooth germ at bell stage (Figure 19).Tooth germ illustrated negative expression for CD34 in all dental layers except basement membrane and in dental sac area showed weak positive of AEC stain (Figure 20).

Figure 15: tooth germs upper one in early bell stage(EBS),lower in advance bell stage (ABS), tongue (T) at the side.H&EX100

A B Figure 16: A :Negative reaction for CD34 in enamel organ (EO), positive reaction in dental sac (DS) and bone formation area (B).AEC stain X200 B: View for dental sac area showed blood vessels arteriol, endothelial cell (arrow) stain positive for CD34 marker ..AEC stain X200
B-Experimental group 1: Histological examination illustrateed apposition of dental hard tissue enamel and dentin with their formative cell ameloblast and odontoblast (Figure 17). Tooth germ showed positive stain high lightened on dental sac cell and blood vessels, while enamel organ illustrated negative stain (Figure 18).

A B Figure 19: A: tooth germ at bell stage in neonatal mouse Showed odontoblast (OD), preameloblast(PAB),stellate reticulum(SR) ,and dental papilla(DP).H&EX200. B: positive reaction of CD34, illustrated in basement membrane (arrow) separates odontoblast (OD) from ameloblast (AB). AEC stain X200

DISCUSSION
Radiofrequency waves emitting from cellular phones and base stations has emerged as a fact which affect increasing number of people by the time. As cellular phone usage gets more widespread, electromagnetic radiation has become an important health problem, which was also reported by the previous studies suggesting the harmful effects of radiofrequency waves on human health (11-14). So far, there has been a
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controversy whether EMF has a negative effect on health or not. Any embryo toxicity of EMF in pregnant mothers raises public apprehension. Concerns about potential susceptibility of embryo, fetal, newborn and the juvenile to EMF are comprehensible due to the immaturity of all organs in their developing stages. A large number of in vivo studies have been carried out in mammals reported only slightly effects on fetus (15, 16) . The present results showed an early tooth development for embryo aged 16th day intrauterine life when its mother was exposed for one hour to radiation, upper and lower teeth showed tooth germ at cap stage with well developed, fused palate, well developed ridges. In comparison to control, which illustrated tooth germ in bud stage? On the other hand exposed for two hours duration to radiation affected the tooth development in versus way, as the results showed retardation in development of teeth and palate. Tooth germ recorded to be missed in 16th day of gestation and hardly oral ectodermic thickness was detected. These results could be explained on the followings: Electromagnetic waves may interact with biological tissues through either thermal or nonthermal mechanisms. The components of the biological system, like those of any other system, are constantly subjected to the random fluctuating electric and magnetic fields associated with the random motion of charges known as Brownian motion or thermal noise. As electromagnetic fields with high frequency can be hazardous in terms of thermal changes, long time exposure to low frequency electromagnetic waves can lead to some unexpected biochemical changes in the body (17). As the frequency interval of analogue phones is between 800 and 900 MHz, digital phones work between 1850 and 1990 MHz frequencies (18). All review of literatures studied mostly on body tissues. But did not find any studies regarding the effects of EMF on tooth development, only few of the studies conducted by Adiguzel et al in 2008 used experimental rat group exposed to GSM-Modulated 900 MHz radiofrequency radiation for 2 hours per day during ten months. At the end of the exposure period, the contents of some elements as Ca, Mg, Zn, and P were measured in the oral tissue. The measurements were performed by Atomic Absorption Spectrophotometry (AAS). However, phosphorus content of teeth was measured by ultraviolet spectrophotometer (UVS). The results showed positive change evidence in rats teeth, and it supports the hypothesis that GSMModulated 900 MHz radiofrequency radiation is
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related with changes in Mg and Zn amounts. However, these findings suggested the possibility of GSM-Modulated 900 MHz radiation to play an important etiological role in mineralization process. Kaya et al 2008 studied the effects of radiofrequency radiation by 900 MHz mobile phone on periodontal tissues and teeth used experimental rat group exposed to mobile phone radiation for 2 h/day, 7 days/week, and 10 months. At the end of the experiment, the histopathological evaluation showed abnormal changes like vasodilatation and focal bleeding area were determined in periodontal ligament, alveolar bone , gingival and pulpa among some individuals. It is well known that embryonic tissue be immature regarding to tooth germ layer be very sensitive and susceptible to injury especially to chemical material like drug and when exposed to radiation in which its effects depend on its duration and frequency. The most possible effects of RF fields on cell receptors alter the protein conformation by Changes in binding to cell receptor proteins. Chiabrera et al in 2000 found that significant changes in the probability of ligand binding could be produced by the modulation of the well shape by RF electric fields below guideline values. Therefore, in these results it seems that exposed for 2 hours daily be harmful to the progenitor cells, while 1 hour seems to enhance and act as stimulator to the stem cells. Moreover the pathologies such as oedema, interstitial hemorrhagia, collagen decomposition, dearrangement of specialized cells such as odontoblast ameloblast ,osteoblast were not detected in dental tissue of the embryo mice of the present study exposed for EMF of both duration(60,120 min.) These results disagreed with results of Kaya et al 2011, who used low frequency magnetic field on pulp tissue of rats. They found it affected odontoblast and fibroblast cells and they attributed to un accurate intensity of EMF that be used on the dental tissue of their experiment. The present result illustrated an early deposition of dental hard tissue in experimental group exposed to EMF for one hour at 18th day of gestation and at one day of neonatal life in comparison to control and the study suggested that exposure for short duration activate specialized dental cells (odontoblast and ameloblast) to deposit organic matrix of enamel and dentin, and may play a role in mineralization and maturation processes. For the experimental group two at the same above periods, it has versus action, it retards development and disturbs the differentiation of specialized dental cells either by

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affected its functions in formation of hard tissues of embryo or due to hormonal changes of pregnant mother. Therefore; these results, which have been obtained from study on animals, should be further investigated and mainly for biochemical mineral analysis of dental tissue. At the same time we didnt encounter any histopathologic studies focused on embryo development concern with tooth germ and palatine growth. Therefore; this study may consider the first one in this field. CD34 is a well-known marker of progenitor cells of blood vessels, stromal tissues, bone cell and mesenchymal cells. Thus, CD34-positive cells have recently been used clinically in the field of vascular and orthopedic biotechnology because of their capacity to assist regeneration of injured tissues. However, as known, the in situ detection of CD34positive cells has not yet been described in the fetus, with the exception of a few organs, Abe et al 2011 study expression of CD34 in human mesenchymal tissue of fetuses (9-15 weeks of gestation). They detected CD34-positive structures as a vessel-like appearance and were regularly arrayed in the viscera, nerves and lymph nodes, in the body wall and extremities. In the present study, immunohistochemistry for CD34 expression in embryonic tissue in different periods of gestation of a mice (16th, 18th and one day postnatal period) was used to include all primitive stem cells suspected to be involved in the formation of the face including teeth, jaws, palate, tongue and other related structures and because it is the first research till the time of prepared thesis studied in vivo dental cell immunoreactions with CD34 markers. The present study illustrateed the followings: strong positive expression of CD34 on cells of dental sac, weak positive on cells of dental papilla and negative immunoreactions for enamel organ cells to CD34, in all studied periods and concern to experimental group of one hour duration. These results could be explained on the facts that dental sac is an ectomesenchymal tissue derived from neural crest cells, the fourth germ layer that form the periodontal tissue and alveolar bone which they are rich in the progenitor of hematopoietic cells, endothelial cell of capillaries, followed by arteries, veins, arterioles, and venules, dendritic interstitial cells around vessels, nerves, muscle and bone cells. And even the related structure such as the nasal cartilage cells expressed positive CD34 marker indicated for the potency of the cells to proliferate and differentiate into multiple mesodermal tissues such as bone, cartilage, muscle, tendon etc. This result supported the histological findings in that exposure to EMF for
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one hour act as stimulator and activates cell proliferation and differentiation. Dental papillae showed weak positive in expression for CD34 and that related to its localized ability to form multispecialized tissue as in dental sac, it only formed pulp although it contains blood vessels, nerves, progenitor mesenchymal cells but not extended like dental sac. The negative immunoreactions of CD34 marker of enamel organ cells attributed to its ectodermal embryonic origin.For experimental group exposed for two hours to EMF, it showed only positive reaction in basement membrane, as a basement membrane is an acellular structure, made up of neutral polysaccarides, fibronectin, laminin, type IVcollagen and as CD34 is a 110kDa transmembrane glycoprotein present on stem cells. Therefore its positive immunoreaction may be related to cross reaction and close similarity with chemical components of antigens. So its expression is not clear and it needs more investigations. Nourbakhsh et al 2011 studied in vitro the Stem cells from human exfoliated deciduous teeth (SHED) which are highly proliferative, clonogenic and multipotent stem cells with a neural crest cell origin. Expressed antigens CD146, CD45, CD90, CD106 and CD166, but not the hematopoietic and stem cell markers, CD34 and CD31was detected. These results were disagreement with our findings. Several reviews on the issue of possible adverse health effects of mobile phones have been published (25). The fact that some environmental factors like GSM-Modulated 900 MHz radiofrequency radiation fields may have some harmful effects continues to arouse more interest especially in last two decades. Some literature has been reported that environmental effects such as GSM-Modulated 900 MHz radiofrequency radiation may affect health status in accordance with the altered physiological conditions (26). For this reason, further studies are needed to reveal the effects of environmental factors on oral tissues and tooth development more clearly.

REFERENCES
1-Stauth JT, Sanders SR, Berkeley CA. Power supply rejection for common-source linear RF amplifiers: theory and measurements .IEEE Xplore .Digital library 2006; 320 (11-13):4. 2- Humphreys L. Cellphones in Public Social interactions in a wireless era. New Media & Society 2005; 7(6):810-33 3-Sage cindy L. Public health implications of wireless technologies, pathophysiology. Patphy 2009; 32 (1): 603-2. 4- Maes AM, Collier, Vershaeve L. Cytogenic effects of 900MHz (GSM) microwaves on human lymphocyte. Bioelectromagnatics 2001; 22: 91-6.

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5- Rubin James, Rosa Nieto-Hernandez, Simon Wessely. Idiopathic Environmental Intolerance Attributed to Electromagnetic Fields. Bioelectromagnetics 2010; 31 (1): 111 6- Habash RW. Elwood JM., Krewski D. Recent advances in research on radiofrequency fields and health J Toxicol Environ Health B. Crit Rev, 2009;12:250-88. 7- Simk M. Cell type specific redox status is responsible for diverse electromagnetic field effects. Current Medicinal Chemistry.2007;14: 1141-52 8-Tompkins K. Molecular mechanisms of cyto differentiation in mammalian tooth development. connect. Tissue Res 2006; 47:111-8. 9- Alappat SR, Zhang Z, Suzuki K, Zhang X, Liu H, Jiang R, Yamada G, Chen YP. The cellular and molecular etiology of the cleft secondary palate in mice. Dev Biol 2005; 277:10213. 10- Meng L, Z Bian, R Torensma, J W Von den Hoff. Biological mechanisms in palatogenesis and cleft palate. J. Dent. Res 2009; 88(1); 22-33. 11-Diner S, Kanan B, merolu S, Gnl B. Dk frekansl elektromanyetik alana maruz kalan farelerde doku lipid peroksidasyonu, askorbik asit ve glutatyon dzeylerindeki deiiklikler. Trkiye Tp Dergisi 1998; 5:173-6. 12- Okudan N, iekiba AE, Bykmumcu M, elik, G kbel H, Salbacak Al. ok dk (50 Hz)frekansl manyetik alann farelerin serum kortizol ve testosteron dzeyleri ile testis histolojisi zerindeki etkilerinin belirlenmesi. Seluk Tp Derg 2006; 22:1-7. 13- Koyu A, C kalp O, zgner F, Cesur G, Mollaolu H, zer MK, et al. Subkronik 1800 MHz elektromanyetik alan uygulamasnn TSH, T3, T4, kortizol ve testosteron hormon dzeylerine etkileri. Genel Tp Derg 2005; 15:101-5. 14- Kaprana AE, Karatzanis AD, Prokopakis EP, Panagiotaki IE, Vardiambasis IO, Adamidis G, et al. Studying the effects of mobile phone use on the auditory system and the central nervous system: a review of the literature and future directions. Eur Arch Otorhinolaryngol 2008; 265:1011-9. 15- Wiley M, Corey P, Kavert R, Harvey J C, Agnew S, Walsh D M. The effects of continous exposure to a 20kHz sawtooth magnetic field on the litters of CD-1 mice. Teratology1992; 46:391-8. 16- Frolen, H, Svedenstal, B, Paulsson L. Effect of pulsed magnetic fields on the developing mouse embryo. Bioelectromagnetics1993; 14:197-204. 17- Rothman KJ. Epidemiological evidence on health risks of cellular telephones. Lancet 2000; 356:1837-40. 18- Koyu A C, kalp O, zgner F, Cesur G, Mollaolu H, zer MK. Subkronik 1800 MHz elektromanyetik alan uygulamasnn TSH, T3, T4, kortizol ve testosteron hormon dzeylerine etkileri. Genel Tp Derg 2005; 15:101-5. 19- Adiguzel O, Dasdag S, Akdag MZ, , Erdogan S, Kaya S, Yavuz I. Kaya F. A. Effect of Mobile Phones on Trace Elements Content in RatTeeth, Operative Dentistry and Endodontics, Diyarbakir, Turkey12008; 999-1000. 20- Kaya S, Celik MS, Akdag MZ, Adiguzel O, Yavuz I, Tumen EC, Ulku SZ, Akkus Z. Trace element and proper human functioning. Biotechnol.&Biotechnol. Eq 2008; 22(3),86973. 21- Chiabrera A, Bianco B, Moggia E, Kaufman JJ. Zeeman Stark modeling of the RF EMF interaction

with ligand binding. Bioelectromagnetic 2000; 21:312-24. 22- Kaya F. Acun, Mehmet Zulkuf Akdag, Can Ayhan Kaya , Suleyman Dasdag , Izzet Yavuz , Nihal Kilinc , Arzum Guler Dogru , Ozkan Adiguzel , Ersin Uysal , Ebru Saribasand Tuba Talo Yildirim. Effects of Extremely Low Frequency Magnetic Fields on Periodontal Tissues and Teeth in Rats. Journal of Animal and Veterinary Advances 2011; 10(22):3021-6. 23-Abe SI, Suzuki M, Cho KH, Murakami G, Cho BH, Ide Y. Cd34-positive developing vessels and other structures in human fetuses: an immunohistochemical study. Surg. Radiol. Anat 2011; Jul 26; 234-71 24- Nourbakhsh N, Soleimani M, Taghipour z, Karbalaie K, Mousavi SB, Talebi A, Nadali F, Tanhaei S, Kiyani GA, Nematollahi M, Nasr-Esfahani MH, Baharvand H.Induced in vitro differentiation of neural-like cells from human exfoliated deciduous teeth-derived stem cells. Int J Dev Biology 2011; 55(2):189-95. 25- Catriona JB, Simon RNC, Smith B, Mason C, Tomkins A, Roberts JG, Sserunjogi L, Tiberindwa JV. Arch. Oral Biol 2004; 49: 705-17. 26- Grobler SR, Theunissen FS, Kotze TJV. The effect of mobile phone radiation on elements of rat teeth. Arch. Oral Biol 2000; 45: 6079.

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Chronological age estimation

Chronological age estimation in adolescent and young adult subjects in relation to mandibular third molar development using digital panoramic image
Jaafar J. Attar, B.D.S. (1) Jamal Ali AL-Taei, B.D.S., M.Sc. (2)
Background: Predicting chronological age in adolescents and young adults can be crucial in Medico legal contexts and the third molar is the only developing tooth during this period that used to determine chronological age. The purpose of this study was to estimate the chronological age based on the stages of mandibular third-molar development following the eight stages (AH) method of Demirjian et al Materials and methods: The sample consisted of 436 Iraqi adolescents and young adults subjects have been chosen with known chronologic age (range, 1424 years) and sex (162 males and 274 female), digital panoramic radiograph had been taken for each examined subject, Demirjians grading has been used to assess third molar development Results: Statistically significant differences (P _ 0.05) in third-molar development between males and females were revealed regarding the development stages D,E and F. Third-molar genesis was attained earlier in males than in females. Statistical analysis showed a strong correlation between age and third-molar development for males (r 2 _ 0.91) and for females (r 2 _ 0.87). Conclusion: It was concluded that the use of mandibular third molar development stages using Demirjian method can be considered as good valuable chronological age indicators in adolescents and young adults Keywords: Third molar; Chronological age; Age estimation. (J Bagh Coll Dentistry 2012;24(2):47-50).

ABSTRACT

INTRODUCTION
In the past decade the number of unidentified cadavers and human remains as well as the number of remains lacking age documentation and therefore requiring age determination has increased. This requires age calculation, not only for differentiating the juvenile from the adult status in criminal law cases, but especially when determining the age of a crime victim and also for estimating chronologic age in relation to school attendance, social benefits, employment, and marriage (1,2). Method of chronological age estimation in adolescents and young adults may be including radiographical examination of the hand and wrist, the medial clavicular epiphyseal cartilage, and finally 3rd molar development observations (3, 4, 5). But compared to bone development, 3rd molar development are less affected by variation in endocrine and nutritional status, and in hand and wrist development it is completed around the age of 18 while 3rd molar development continues until the early twenties when the development of almost permanent teeth may be completed, and regressive changes in teeth with increasing age may not yet appear at that age.

Therefore developing 3rd molar is the only reliable biological dental indicators variable and readily assessable from dental radiographs during adolescence and the transitional period to adulthood, Indeed a great variation in position, morphology, and time of formation(6,7,8) .Up to now several studies have been undertaken in different populations these studies show that 3rd molar development varies slightly between different populations, making population-specific studies necessary. Recently, for different ethnic groups, numerous reports have been published on the evaluation of third-molar development (9, 10). Panoramic radiography is a radiological technique for producing a single image of the facial structures that include both the maxillary and mandibular dental arches and their supporting structures. Digital radiography is considered to be a great enhancement to the diagnostic radiography due to its radiation dose reduction, improved image properties, improved storage and transportability of the Image and reduce equipment and time needed to produce a superior image (11). The aim of this study was to estimate chronological age and gender in adolescent and young adult subjects based on stages of mandibular third molar according to Demirjian method using digital panoramic image.

MATERIALS AND METHODS


(1) M.Sc. Student, oral and maxillofacial radiology, oral diagnosis Department, College of Dentistry, Baghdad University. (2) Assistant Professor, oral diagnosis Department, College of Dentistry, Baghdad University.

Samples selection: In this cross-sectional study, dental panoramic image of 450 Iraqi subjects with known chronologic age and sex were selected.
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Selection criteria included the following: Adolescent and young adult Subjects; Well nourished and free of any known serious illness; Normal growth and development and dental conditions, for example, no impactions, congenital absence, or transposition of teeth. Exclusion criteria excluded the following: Image deformity affecting third molars; and Panoramic image showing obvious dental pathology. Fourteen films were excluded for poor radiographic quality, and for agenesis of the third molars. The final sample consisted of 436 Panoramic image from Iraqi individuals of known chronologic age and sex. Mean age range of the 436 patients for both genders was (14- 24 years). All assessments were performed by digital panoramic image in computer to ensure contrast enhancement of the tooth images. Examination and classification covered the development phase of the left mandibular molar third and, when not present, the Contra lateral molar was considered. Tooth calcification was rated according to the method described by Demirjian et al 12 in which one of eight stages of calcification, A to H, was assigned to the third-molar tooth (Figure 1).

All statistical analyses were performed using SPSS version 15.0. (Statistical Package for Social Sciences) To test the reproducibility of the assessments of dental development stage, two investigators reevaluated randomly selected panoramic radiographs from 10% of the same male and female subjects after the first evaluation. Interand intra observer agreements were determined using the Binominaltest (non-parametric test)

RESULTS
Repeated scorings of a subsample of 40 radiographs indicated no significant intra- or inter observer differences (P_0.05). Intra observer consistency was rated at 98%, whereas inter observer agreement was 95%. The third-molar formation process was examined in both sexes, and the mean ages and standard deviations for the Demirjian stages are described in (Table 1). Data for Demirjian stages A, B and C was omitted from the study because no teeth in stages A and B were noted and less than 1% was noted in stage C for the present study In both male and female sample groups there is strong positive relation ship between the dental development stage of mandibular third molar and chronological age (p<0.001, for both sexes) Statistically significant differences (P _ 0.05) were revealed in third-molar development between males and females regarding the calcification stage D and stage E. These differences indicated that third-molar genesis attained the Demirjian formation stages earlier in males than in females.

Figure1: panoramic image shows third molar development.


The first four stages (AD) show crown formation from the beginning of cusp calcification to completed crown, and the second four (E H) root formations from initial radicular bifurcation to apical closing. Descriptive statistics were obtained by calculating the means, standard deviations, and range of the chronologic ages for the eight stages of dental development. Statistical analyses were performed using the Student's t-test between sex and age. ANOVA test was used to test the statistical significance of difference in mean between developmental stages groups of mandibular molar.Pearson's correlation coefficient to test statistical significance, direction and strength of linear correlation between 2 quantitative normally variables.
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Table 1: Descriptive statistic of both genders


Sex Stages D E F G H Sex D E F G H Male Mean SD 14.40 0.627 15.79 1.503 17.85 1.405 19.00 1.275 21.32 1.561 Female 15.09 1.460 16.66 1.250 18.07 1.557 19.46 1.444 21.36 1.314

DISCUSSION
Chronologic age estimation by tooth development has been used over a long period. Tooth development is an accurate measure of chronologic age that seems to be independent of

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exogenic factors such as malnutrition or disease


(13-15).

The third-molar calcification stage is one of the few tools that can be used to assess age when development is nearing completion during adolescence when the third molar is the only remaining variable dental indicator (16). The differences between populations, the different methodology, and the dissimilarity among observers are other important shortcomings. In the present study, to overcome some of these shortcomings, all selected subjects were evaluated by two well trained observers using eight stages according to the method of Demirjian et al.12 a range of different classifications for evaluating tooth mineralization is available. In the past, different classifications were presented by Gleiser and Hunt, 17 Moorrees et al, 18 Kohler et al.19 and Kullman et al, 20 However, some of these classifications identify a large number of stages that are hard to delimit from each other. Demirjian et al12 presented a classification distinguishing four stages of crown development (stages AD) and four stages of root development (stages EH). The system avoids any numeric identification of stages so as not to suggest that the different stages represent processes of the same duration. The stages proposed by Demirjian et al12 are defined by changes of shape, independent of speculative estimations of length. Dhanjal et al 21 investigated the reproducibility of different radiographic stage assessment of third molars and concluded that the method of stage assessment of third molars developed by Demirjian et al 12 performed best not only for intra- and inter examiner agreement, but also for the correlation between estimated and true age. Therefore, this classification seemed to be the most appropriate for our study. In the present study examined the mean ages of each stage for male and female patients statistically significant differences (P_0.05) in third-molar development between male and female subjects were revealed regarding calcification stages D and E. These significant differences indicated that thirdmolar genesis in males attained these Demirjian formation stages 6 to 8 months earlier than in females. This observation was consistent with previous studies, which report that the mean age at some of the development stages was lower for males than for females in the following populations: Hispanics, 22; Belgian whites, 23 Swedes, 20 or people of Spanish origin9.
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However, other researchers have demonstrated similar mean age values and distributions for sexes (10, 24,25). The stage of development of the third molar has a practically linear relation to the age of the subjects, whether male or female. Statistical analysis shows a stronger correlation for male (r 2_0 .91) than for female (r 2 _0 .87) subjects. These results also agree with studies on other populations 9.

REFERENCES
1. Ritz-Timme S, Cattaneo C, Collins MJ, Waite ER, Schutz HW, Kaatsch HJ, Borrman HI. Age estimation: the state of the art in relation to the specific demands of forensic practice. Int J Legal Med 2000; 113:129 36. 2. Willems G. A review of the most commonly used dental age estimation techniques. J Forensic Odontostomatol 2001; 19: 917. 3. Greulich WW, Pyle SI. Radiographic Atlas of Skeletal Development of the Hand and Wrist. Stanford, CA: Stanford University Press; 1959. 4. Kreitner KF, Schweden FJ, Riepert T, Nafe B, Thelen M.,Bone age determination based on the study of the medial extremity of the clavicle. Eur Radiol 1998; 8: 1116-22. 5. Olze A, Schmeling A, Taniguchi M, Maeda H, Van Niekerk P, Wernecke KD, Geserick G. Forensic age estimation in living subjects: the ethnic factor in wisdom teeth mineralization. Int J Leg Med 2004; 118:1703. 6. Engstrom C, Engstrom H, Sagne S. Lower third-molar development in relation to skeletal maturity and chronological age. Angle Orthod 1983; 53:97106. 7. Zeng DL, Wu ZL, Cui MY: Chronological age estimation of third molar mineralization of Han in southern China. Int J Leg Med 2010; 124:11923 8. Willems G: A review of the most commonly used dental age estimation techniques. J Forensic Odontostomatol 2001; 19:9-17. 9. Prieto JL, Barberia E, Ortega R, Magana C. Evaluation of chronological age based on third-molar development in the Spanish population. Int J Legal Med 2005;119:34954 10. Bolanos MV, Moussa H, Manrique MC, Bolanos MJ. Radiographic evaluation of third-molar development in Spanish children and young people. Forensic Sci Int 2003; 133: 212 9. 11. White SC, Pharoah MJ. Oral Radiology Principles and Interpretation, 6th ed. China: Mosby Company; 2009. 78-100. 12. Demirjian A, Goldstein H, Tanner JM. A new system of dental age assessment. Hum Biol 1973; 42: 21127. 13. Nambiar P, Jaacob H, Menon R. Third-molars in the establishment of adult statusa case report. J Forensic Odontostomatol 1996; 14: 303. 14. Kullman L. Accuracy of two dental and one skeletal age estimation method in Swedish adolescents. Forensic Sci Int 1995; 75: 22536. 15. Melsen B, Wenzel A, Miletic T, Andreasen J, VagnHansen PL, Terp S. Dental and skeletal maturity in adoptive children: assessments at arrival and after one year in the admitting country. Ann Hum Biol 1986; 13:1539.

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16. Tanner JM, Whitehouse RH, Marshall WA, Healy MJR, Goldstein H. Assessment of Skeletal Maturity and Prediction of Adult Height (TW2 Method). London, England: Academic Press; 1975. 17. Gleiser I, Hunt EE. The permanent mandibular first molar; its calcification, eruption and decay. Am J Phys Anthropol 1955; 13: 25384. 18. Moorrees CFA, Fanning EA, Hunt EE. Age variation of formation stages for ten permanent teeth. J Dent Res 1963; 42:14901502. In: Olze A, Taniguchi M, Schmeling A, Zhu BL, Tamada Y, Maeda H, Geserick G. Comparative study on the chronology of third molar mineralization in a Japanese and a German population. Leg Med 2003; 5:25660. 19. Kohler S, Schmelzle R, Loitz C, Puschel K, Entwicklung des Weisheitszahnes als Kriterium der Lebensalterbestimmung. Ann Anat. 1994; 176:339 45. In: Olze A, Taniguchi M, Schmeling A, Zhu BL, Yamada Y, Maeda H, Geserick G. Comparative study on the chronology of third-molar mineralizationm in a Japanese and a German population. Leg Med 2003; 5: 25660. 20. Kullman L. Accuracy of two dental and one skeletal age estimation method in Swedish adolescents. Forensic Sci Int 1995; 75: 22536. 21. Dhanjal KS, Bhardwaj MK, Liversidge HM. Reproducibility of radiographic stage assessment of third-molars. Forensic Sci Int 2006; 159:747. 22. Solari AC, Abramovitch K. The accuracy and precision of third-molar development as an indicator of chronological age in Hispanics. J Forensic Sci 2002; 47: 5315. 23. Thorson J, Hagg U. The accuracy and precision of the third mandibular molar as an indicator of chronological age. Swed Dent J 1991; 15:1522. 24. Willershausen B, Loffler N, Schulze R. Analysis of 1202 orthopantograms to evaluate the potential of forensic age determination based on third-molar developmental stages. Eur J Med Res 2001; 28:377 84. 25. Arany S, Iino M, Yoshioka N. Radiographic survey of thirdmolar development in relation to chronological age among Japanese juveniles. J Forensic Sci 2004; 49: 5348.

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Diagnosis of the angular

Diagnosis of the angular hyperkeratotic lesions and the incidence of the etiologic factors
Jamal N. Ahmed, B.D.S., M.S., Ph.D. (1)

ABSTRACT
Background: Hyperkeratotic lesions located at the angle of the mouth are common among patients attending dental clinics. Most dentists are unaware of it since the patients are not seeking care. The purpose of the present study was to find out the incidence of the diagnosed lesions and their relation with the etiologic or initiating factors. Materials and methods: A total of (112) patients (62) males and (50) females having angular hyperkeratotic lesions were selected from patients attending the dental clinic in Baghdad dental school. The clinical diagnosis and the progression of the lesions were conducted by using 1% toluidine blue stain to confirm the premalignant potentials and to delineate the margins of the lesion for the biopsy. Microscopic examinations were done for the confirmation of the final diagnosis. The associating factors like smoking, alcohol, dental irritation, prosthesis, systemic diseases, and angular chelitis were recorded in the patient information sheet for the result analysis. Results: The results showed that the benign hyperkeratotic lesions were the higher (36.6%) in distribution, while the malignant neoplasms were the 2nd (25.89%) in frequency, followed by premalignant lesions (21.42%), lichen planus (12.5%), and benign growth (3.57%). Smoking habit was the most common associating factor (54.6%), followed by angular chelitis (48.2%), dental irritation (43.7%), systemic diseases (35.7%), dental prosthesis (28.5%) and alcohol consumption 0.05%. Conclusion: The hyperkeratotic lesions occurred in a wide range of ages. The benign lesions were the most common types. However a significant number of cases had premalignant and malignant changes. The presence of the associating factors acting alone or in combination were having a role in the existence of the lesions. The premalignant potentials increase with age and the chronicity of the associating factors such as smoking and angular chelitis were having a significant role in existence of the lesions. In addition, the results showed that the angular hyperkeratotic lesions existed in the majority of the patients were bilateral in behavior. Key words: Angular, Hyperkeratotic, Etiologic factors. (J Bagh Coll Dentistry 2012;24(2):51-55).

INTRODUCTION
Hyperkeratotic lesions leukoplakias are commonly seen on the oral mucous membrane. Fortunately, most are benign and justify little clinical concern once a definitive diagnosis is made1. However, a small proportion of these lesions represent dysplastic, early malignant or neoplastic lesions of the surface epithelium. Idiopathic leukoplakia is reserved for white lesions suspected of cancerous or precancerous character when direct cause or specific benign condition explains the abnormal appearance.2, 3 A variety of local irritations such as tobacco products, hot and spicy foods, occlusal trauma, sharp prosthesis, presence of candida albicans, acting alone or in combination produce keratotic lesions in certain individuals.1,4 Squamous cell neoplasms of the oral cavity and leukoplakia share many of the same etiologic factors.5 Diagnosis of the dysplastic lesion and early squamous cell carcinoma could not be determined based on the clinical findings only. Toluidine blue stain is a reliable clinical method and proposed as a vital stain to disclose dysplasia and carcinoma in situ. The stain was used for the detection of premalignant and malignant lesions of the oral cavity.6

(1)

Assistant professor, department of oral diagnosis. College of Dentistry, University of Baghdad.

The investigators confirmed the property of toluidine blue discoloration to verify clinically suspicious lesions as neoplastic to delineate margins of premalignant and malignant growth and to detect unnoticed or satellite tumors7. The high sensitivity of the test appears to offer a feasible diagnostic control and lesions that stain with toluidine blue should be considered carcinoma unless proven by biopsy.8-10 When clinical hyperkeratotic lesions are studied microscopically they could be seen to embrace various histologic changes that shows only increase keratosis to invasive squamous cell carcinoma. These differences cannot be identified clinically so to establish a specific diagnosis the lesion need to be examined microscopically.10,11 Differential diagnosis of white lesions is based on location, history, and other physical findings. The distribution of leukoplakia lesions is of diagnostic value in the transmission to malignancy. The tongue and the floor of the mouth are the most common locations of malignant lesions; however the cheek and lips are the common sites of leukoplakia with dyskeratosis.12 A significant number of patients attending the oral diagnosis clinic seeking dental treatment are having white lesions, and may be unaware of it since it is asymptomatic. In practice, the angle of the mouth is exposed to fungal infections,

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occlusal trauma, smoking irritations, and is the common site of the lesion. The purpose of this study was to find out the incidence of the diagnosed hyperkeratotic lesions that are existed at the angle of the mouth, in addition to the frequency of the relation with the etiologic or initiating factors.

MATERIALS AND METHODS


A thorough clinical examination of the oral soft tissue was conducted for patients attended the oral diagnosis clinic, college of dentistry, university of Baghdad in the period between 1997-2005. Emphasis was done on angular hyperkeratotic lesions. A total of 112 patients were selected for this study. They were (62) males and (50) females with age ranges between (11-90) years. The information about systemic diseases, smoking habits, presence of traumatic factors, and presence or absence of angular chelitis were collected and registered in the case sheet. The clinical method of investigation was done by applying toluidine blue stain protocol to the mucosal lesion.7,10,13 The lesion was washed with water for few seconds for the removal of debris present, then rinsed with 1% acetic acid and followed by swabbing with a piece of cotton socked with 1% toluidine blue stain. After application of the stain acetic acid was used again for discoloration. The lesions that picked up the royal blue stain were considered malignant neoplasm (fig. 3). While the lesions that have picked up few amount of the stain as dark spots inside a white lesion considered precancerous lesion (fig. 2). The entire positive and the clinically suspicious negative reacted lesions were biopsied and examined under the light microscope for the final diagnosis. The presence of dysplastic changes within the epithelium regardless of the severity was considered premalignant. The suspicious lesions were selected and stained with PAS stain for the detection of candida albicans. Presence of candidal hyphe within the lesions was considered candidal leukoplakia. The data were collected and analyzed for the final results.

lesions (36.6%). While the malignant neoplasms were the 2nd in frequency (25.89%) having mainly sqamous cell carcinoma (19.64%) which was highest than verrucous carcinoma (3.57%) and ca in situ (2.67%). Among the premalignant lesions which represent (21.42%) of the angular hyperkeratotic lesions, epithelial dysplasia had the highest distribution (11.6%), followed by candidal leukoplakia (7.14%) and verrucous leukoplakia (2.6%). Benign growths which were mostly of viral origin represent the least in distribution (3.57%), including papillpma, and verrucous vulgaris. Lichen planus (dermatosis) was included when the diagnosis was suspicious and should be located at the angle of the mouth (fig.4). It was not considered whether they were erosive and non-erosive and the result was (12.5%) of the total cases. Table 2 summarized the relation between the lesions in the males and females with the associating factors. The table was descriptive rather than analytic, because number of cases of the specified lesions was small, so that the associating factors did not give a conclusion about the effect of these factors on the specified lesion. However, the total numbers showed smoking habit (54.46%) was the highest in frequency. Angular chelitis was also high (48.2%) because the number of patients having premalignant and malignant lesions showed significant number of lesions associated with candidiasis. The effect of dental irritation and cheek biting (43.7%) and a history of presence of removable or fixed prosthesis (28.5%) showed a relation with benign hyperkeratosis in particular. Presence of systemic diseases (oral and skin autoimmune diseases, diabetes, hypertension, anemia, vitamin deficiency and drug allergy) as an associating factor of the lesions was seen in 35%. Alcohol consumption, regardless of the amount used, was the least 0.05% in frequency.

DISCUSSION
The clinical manifestations of various white lesions are the same. However, the histologic appearance implicate different histologic diagnosis varies in nature from benign to highly malignant potentials. Squamous cell carcinoma is the most common malignant disease of the oral cavity and one of the few potentially fatal conditions the dentist is likely to initially identify. The site and distribution of the hyperkeratotic lesions in the oral mucosa is considered an important factor in the diagnosis and prognosis of the disease.1,3,12 About 71% of the hyperkeratotic lesions of the oral cavity are benign in nature.12
52

RESULTS
According to the clinical and histologic diagnosis, the white lesions were classified into benign lesions, premalignant lesions, benign growth, malignant neoplasms, and lichen planus. Table 1 shows the general classification of the lesions and the frequency distributions of the specific lesions in their categories. Benign hyperkeratotic lesions represent the most frequent among other angular
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Angular benign hyperkeratotic lesions represent the majority of the cases diagnosed in this study but the percentage (36.6%) shows less if compared with leukoplakias distributed in other sites of the oral mucosa. Locations and distributions of hyperkeratotic lesions in the oral mucosa indicate reliability to malignant transformation.11,14 The results showed neoplastic lesions (carcinoma in situ, verrucous carcinoma, and squamous cell carcinoma) are in the second place of occurrence at the angle of the mouth compared with other hyperkeratotic lesions at the same site. It was found that leukoplakia with dyskeratosis occurs in the buccal mucosa as a first site in frequency compared with the other sites of the oral mucosa.15 Our findings revealed (21.42%) of the total hyperkeratotic lesions. Epithelial dysplasia is the majority diagnosed followed by candidal leukoplakia, and verrucous leukoplakia respectively. Lichen planus whether erosive and non-erosive types were included when the location of the lesion was present strictly at the angle of the mouth. In some cases the plaque type was confusing with planer type leukoplakia in the clinical form, and the erosive types were similar to dysplastic lesions in their form of mixed red and white lesion (fig. 4). Benign neoplastic growths were seen at the angle of the mouth and diagnosed as papilloma and verrucous vulgaris. They were viral in origin and diagnosed clinically and histologically. Verrucous vulgaris was seen in young patients and one of the cases was an 11 year old child attended the clinic having white verrucous lesion restricted at the angle of the mouth (fig. 5). The lesion at the beginning gave the clinical manifestation of a premalignant or even a malignant lesion, but there were papillomas located at the hands. The parent refused to take a biopsy so that the diagnosis was based on the associated lesions of the hand and, in addition the regression of the lesion after following up the case. The existence of the angular hyperkeratotic lesions in a wide range of age groups with no significant difference in both sexes made them of no diagnostic value in general. However, they were useful in the diagnosis of the specified lesions if correlated with the associated factors. The most common etiologic factor implicated in the development of oral epithelial dysplasia and squamous cell carcinoma is smoking habit. Buccal mucosa at the angle of the mouth is the early site exposed to thermal irritation due to smoking.17,18 Smoking habits were noticed in significant percentage of the total lesions and represent the higher associating factor. It has been
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published that Smoker keratosis was oftenly benign and the development of dysplastic lesions apparently require several decades of exposure because leukoplakia is unusual among young patients before 40 years and is more typical after the fifth dacade.12 This agree with our results that premalignant lesions are existed in an elderly ages of the males and females. Angular mucosa is commonly subjected to various irritation factors and the angle of the mouth is the common site exposed to trauma from occlusion of the canine and premolars and removable or fixed prosthesis. The general condition of the oral mucous membrane as influenced by both regional and systemic disorders is important in enhancing effectiveness of the locally active factors. Systemic diseases such as nutritional deficiency, anemia, diabetes mellitus, lichen planus, xerostomia, and autoimmuine diseases...etc are associated with atrophic changes in the oral mucous memberene that predispose these patients to both leukoplakia and oral carcinoma.19,20 In this study they were commonly noticed associated with benign, premalignant, and malignant lesion as well as with lichen planus. The presence of chronic infections at the angle of the mouth due to candida albicans was seen associated with different specific lesions and the malignant lesions in particular. This was probably more superimposing in nature than as initiative factor. However, when hyperkeratosis at the angle of the mouth associated with chronic irritation, inflammation or infection due to angular chelitis, and associating systemic diseases in adult and old patients, biopsies were required to identify the dysplastic changes by using tolidine blue and microscopic examination. Alcohol consumption was the least associating factor noticed in this study, the reason may be some patients deny this habit since socially and religiously is unaccepted in this country. A point worth mentioning during the clinical examination, it was noticed that the majority of cases included in this study showed the angular hyperkeratotic lesions were distributed in a bilateral behavior.

REFERENCES
1. 2. Norman KW, Paul WG. Differential diagnosis of oral lesions: White lesions of the Oral Mucosa. 5th ed. The C.V. Company; 1997. p. 96-126. Bouqnot, JE, Gorlin, RJ. Leukoplakia, Lichen planus, and other oral keratosis in 23,616 white Americans over the age of 35 years. Oral Surg Oral Med Oral Pathol 1986; 61:373-81. Silverman SJ, Gorsky M, Lozada F. Oral leukoplakia and malignant transformation: a follow-up study of 257 patients. Cancer 1984; 53:563-8.

3.

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4.

Arendrof TM, Walker DM, Kingdom RJ, Roll J. New Combe, RG, Tobacco smoking and denture wearing in oral candidal leukoplakia. Br Dent J 1983; 155: 340-3. 5. Llewedyn J, Mitchell R. Smoking alcohol and oral cancer in southeast Scotland: a 10 year experience, Br J Oral Maxillofac Surg 1994: 32:146-8. 6. Epstein JB, Oakley C, Millner A, Emerton S, van der Meij E, Le N. The utility of toluidine blue application as a diagnostic aid in patients previously treated for upper oropharyngeal carcinoma Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 83(5): 537-47 7. Miller RL, Simms BW, Gould AR. Toluidine blue staining for detection of oral premalignant lesions and carcinomas. J Oral Pathol 1988;17:73-8. 8. Rosenberg D, Cretin S. Use of meta-analysis to evaluate tolonium chloride in oral cancer screening. Oral Surg Oral Med Oral Pathol 1989; 67: 621-7. 9. Mashberg A. Revaluation of toluidine blue application as a diagnostic adjunct in the detection of asymptomatic oral squamous carcinoma. Cancer1980; 46: 758-63. 10. Upadhyay J, Rao NN, Upadhyay RB, Agarwal P. Reliability of toluidine blue vital staining in detection of potentially malignant oral lesions - time to reconsider. Asian Pac J Cancer Prev 2011; 12(7): 1757-60. 11. Waldron CA, Shafer WG. Leukoplakia revisited: a clinicopathologic study of 3,256 oral leukoplakias, Cancer 1975; 36:1386.

12. Coleman, GC, Nelson FN. Principles of oral diagnosis; Differential diagnosis of white lesions. Mosby yearbook. 1993:278-99. 13. Epstein JB, Gneri P. The adjunctive role of toluidine blue in detection of oral premalignant and malignant lesions. Curr Opin Otolaryngol Head Neck Surg. 2009; 17(2):79-87. 14. Bhaskar SN. Synopsis of oral pathology: Surface lesions of the oral mucosa: Sixth Ed., Published by the C.V. Mosby Company 1981; 373-460. 15. Bouquot, JE. Reviewing oral leukoplakia: Clinical concepts for the 1990s. J Am Dent Assoc 1991;122:80. 16. Banoczy J, Csiba, A. Occurrence of epithelial dysplasia in oral leukoplakia, Oral Surg 1976; 42: 766. 17. Berry HH, Landwerlen, JR. Cigarette smokers lip lesion in psychiatric patients, J Am Dent Assoc 1973; 86: 675. 18. Salonen L, Axell, T, Helldin, L. Occurrence of oral mucosal lesions, the influence of tobacco habits and an estimate of treatment time in an adult Swedish population. J Oral Pathol Med 1990;19:170. 19. Park KK, Brodell RT, Helms SE. Angular cheilitis, part 2: nutritional, systemic, and drug-related causes and treatment. Cutis 2011; 88(1): 27-32. 20. Burket LW. Burkets Oral Medicine: Diagnosis and treatment. 9th ed. JP Lippincott Company; 1994. p.86.

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


Classification of the lesion Benign lesions Diagnosis Benign epithelial hyperkeratosis Epithelial Dysplasia Candidal leukoplakia Verrucous leukoplakia 41 Number (per%) (36.6%) Age Age Female range range 53.2 50.4 23 18 (22-80) (23-85) 50 60.4 (40-58) 5 (45-75) 8 52.7 2 56 6 (26-90) 1 (47-75) 2 61.5 73 (58-65) 63.1 53.73 8 16 (45-75) (26-90) 11 1 1 20 46 2 0 0 (42-50) 28.5 3 1 20 (11-50) 58 (46-70) 1 60 2 60.75 0 0 4 (48-73) 8 55 14 58.4 (40-72) (42-81) 59 57.5 20 9 (42-81) (40-75) 53.6 55.8 8 6 (24-85) (25-60) 62 53 50 40.5 (55.4%) (11-85) (44.6%) (20-90) Male

Premalignant lesions

13 8 3

(11.6%) (7.14%) (2.67%)

Total Verrucous vulgaris Papilloma Benign growth Total

24 2 2 4

(21.42%) (1.78%) (1.78%) (3.57%)

Malignant neoplasm

Carcinoma in situ Verrucous carcinoma Squamous cell carcinoma

3 4 22

(2.67%) (3.57%) (19.64)

Total Dermatosis Total Lichen planus

29 14 112

(25.89%) (12.5%) (100%)

Table 2: The factors associated with angular hyperkeratotic lesions


Diagnosis Benign hyperkeratosis Epith.dysplasia Candidal leukoplakia Verrucous leukoplakia Carcinoma in situ Verrucous carcinoma Squamous cell carcinoma Verrrucous vulgaris Papilloma Lichen planus Total Gender F M F M F M F M F M F M F M F M F M F M number 18 23 8 5 6 2 2 1 1 2 0 4 8 14 1 1 0 2 6 8 112 (100%) Smoker 6 18 5 4 4 2 1 0 1 1 0 3 4 8 0 0 0 0 1 3 61 (54.60%) Alcohol 0 3 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 6 (0.05%) Dental Irritation 8 11 5 3 3 2 0 0 1 1 0 3 2 6 0 0 0 1 1 2 49 (43.70%) Prosth. 7 9 4 3 2 1 0 0 0 0 0 0 0 3 0 0 0 0 2 1 32 (28.5%) Systemic Disease 7 6 3 2 2 0 1 0 0 0 0 1 6 6 0 0 0 0 4 2 40 (35.70%) Angular Chelitis 4 5 5 3 5 4 1 1 1 1 0 1 7 12 0 0 0 0 1 3 54 (48.20%)

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Pre-implant computed tomography and insertion torque measurement in qualitative determination of trabecular bone density
Mahmood J. Hamzah, B.D.S. (1) Jamal A. Al-Taei, B.D.S., M.Sc. (2)

ABSTRACT
Background: Bone density is a very important factor in the successful plan of implant treatment. The aim of the study is to evaluate the trabecular bone density of potential dental implant sites in different region of the jawbone by using Computerized Tomography (CT) , and the relationship between bone density and insertion torque. Materials and method: In this clinical study 64 patients were treated with 120 Xive FRIADENT DENTPLY system implants. The implant recipient sites were divided in two groups according to gender; 60 in males and 60 in females and each group was divided into subgroups according jaw (maxilla and mandible) and region (anterior and posterior). The bone density of each implant recipient site was recorded in Hounsfield units (HU) using CT. The maximum insertion torque (Ncm) values were recorded with torque controlling motor. Results: There was a significant correlation between bone density and insertion torque in males (r=0. 983, p <0.001) and females (r=0.955, p <0.001).The trabecular bone density values were (68298 HU, 481104 HU, 41392 HU, and 26367 HU) values in the anterior mandible, posterior mandible, anterior maxilla, and posterior maxilla, respectively. Trabecular bone density was higher in males in comparison to females and the bone quality was higher for the mandible than for the maxilla, and higher for the anterior region than for the posterior region of these bones. In females there is no significant difference in bone density (p<0.05) between the posterior mandible and anterior maxilla and between males and females at posterior maxilla (p<0.001). Conclusion: Trabecular bone density is a key determinant for clinical success; CT is a useful tool for assessing the bone density Key words: dental implants, computerized tomography, insertion torque, bone density. (J Bagh Coll Dentistry 2012;24(2):56-61).

INTRODUCTION
Dental implants have become a popular alternative in oral rehabilitation in the past two decades; even though the clinical outcome of an implant is influenced by many factors, including the implant body, skill of the surgeon, and the oral environment. The key factor for success is the primary stability at implant placement. The quality of the alveolar bone is the most important factor for achieving good primary stability (1, 2). There are many different definitions of bone quality, but it is generally presented as the sum of all of the characteristics of bone that influence its resistance to fracture (3). The term bone quality was introduced to refer to the different bone density types. In the field of dentistry, Lekholm and Zarb classified jawbone density into four types based on the amounts of cortical bone versus trabecular bone evident on pantograph film (4, 5) . Computed tomography (CT) is one of the most useful medical imaging techniques for assessing not only the structure of the body tissue, but also its density. Theoretically, the bone density, which is measured in Hounsfield units (HU), is directly related to the tissue attenuation coefficient (68).
(1) Master Student, College of Dentistry, University of Baghdad. (2) Assistant Professor, Department Oral Radiology, College of Dentistry, University of Baghdad.

Some researchers have reported that CT is a good tool for evaluating the bone density at potential dental implant sites (2, 4, 7, 917). The quality of bone in the jaw has been studied previously (4, 9, 11) but not in the Asian population. The aim of this study was therefore to evaluate the trabecular bone density of potential dental implant sites in different regions of the Iraq jawbone using CT images.

MATERIALS AND METHODS


A total of 73 Iraqi patients aged 23-45 years old, males and females, attend our private clinic in Holy Karbala City. The study extended from November 2010 to July 2011. Out of these73 patients full or partial edentulous, 64 subjects (31 males & 33 females) were included in this study. The implant recipient sites (120) were divided in two groups according to gender; 60 implant recipient sites in males and 60 implant recipient sites in females and each group was divided into subgroups according to the jaws (maxilla and mandible) and regions (anterior and posterior).15 in anterior maxilla, 15 in posterior maxilla, 15 in anterior mandible and 15 in posterior mandible. Selective criteria of study sample: The patients were selected according to medical and potential implant site evaluation as follows:

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a- Medical evaluation: Sample individual should have no history of any systemic disease that might affect bone metabolism like 1- Diabetes Mellitus. 2- Tuberculosis. 3- Cushing's syndrome. 4- Hyperparathyroidism. 5- Generalized osteoporosis. 6- Heavy smokers. 7- In patients with a long period of time having steroid therapy. 8- Radiotherapy (60GY) in patients with head and neck cancers (18-20). b- Potential implant site: 1-The Region of interest is larger than 9.6mm. 2- Diameter greater than 3.5mm. 3- longer than 6 mm in the alveolar trabecular bone. Material X-ray machine A spiral Computed Tomography (CT) machine (GE LighSpeed VCT, 64 slice, USA) (in IRAQI MEDICAL CENTER- Holy KERBALA City) which will be calibrated daily according to the manufacturer's instruction. A range of 5 cm will be covered in 9.9 seconds, Kv 140, mA 334, rot 0.50 second, slice width 1.25 mm and pixel size 512x512. Dental implant: The dental implants used in this study are XiVE Dentsply Friadent system. XiVE implants are available in diameter D 3.0- D 5.5 mm and in lengths of 8-18 mm. Torque controlling motor: High torque micro motor (FRios unit Si DENTSPLY FRIADENT), (W&H; Austeria) and contra-angle speed reduction (20:1) hand piece (W&H; Austria). Statistical data analysis: The data were processed and analyzed using SPSS (Statistical Package for Social Sciences) version 19 computer software. A. Use t-test to compare the mean of two groups (males and females). B. Pearson correlation to test the linear relationship between each two variables (average bone density and insertion torque). C. ANOVA test to test for differences in means of more than two groups. When the result proves significant this would be followed by LSD test. D. LSD (Least significant difference test) to check which two groups are different

(anterior mandible, posterior mandible, anterior maxilla and posterior maxilla. E. P value of less than the 0.05 level (P<0.05) of significance was considered statistically significant.

RESULTS
1-Relation between the average bone density (BD) and the maximum insertion torque (torque) in males and females The BD and torque in males (541229 HU, 338 N cm) were higher than females (378123 HU, 27 4 Ncm) and highly significant difference between males and females as shown in table (1). There is significant correlation between average bone density and maximum insertion torque in males and females table (2). 2- Relation between the maxilla and mandible in average bone density (BD) and the maximum insertion torque. BD and the torque were significantly higher in the mandibles (581202 HU, 354 N cm) in comparison to the maxillae (33880 HU, 263 N cm) and highly significant difference between mandibles and maxillae. There is significant correlation between average bone density and the maximum insertion torque in maxillae and mandibles table (3). There is significant correlation between BD and the torque in maxillae and mandibles table (4). 3- Relation between the maxilla and mandible in average bone density and the maximum insertion torque at each region in males and females In males Higher BD and the torque had been found in the anterior mandible followed by the posterior mandible, then anterior maxilla and the last posterior maxilla. For the differences among the four regions in males figures (1) & (2); ANOVA test show a high significant difference in the BD and the torque in regions (p< 0.01). The LSD test also shows a high significant difference in the BD and the torque in each region in relation to others. In females Higher BD and the torque had been found in anterior mandible followed by the posterior mandible, then anterior maxilla, and the last posterior maxilla. For the differences among the four regions in females' figures (1) & (2). ANOVA test shows a highly significant difference in the BD and the torque in regions. The LSD test also shows a no significant difference in the BD and the torque between the posterior mandible and the anterior maxilla (p<0.05).

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Figure 1: Box chart average of bone density in different regions in males and females

Figure 2: Box chart maximum insertion torques in different regions in males and females.

DISCUSSION
Bone density Many studies have demonstrated that the survival rate of an implant is significantly affected by the host bone quality (21-25), and hence a preoperative evaluation of the bone condition is essential for assisting the dentist when planning implant therapy. The use of CT, which is more objective and reliable for the assessment of the bone density of the patients requiring implant therapy, was introduced (26). In this study, alveolar trabecular bone density was evaluated in different regions of the jawbone from spiral CT images. It is not passable to make a direct comparison between the present study and previous studies because many previous studies on the bone density from CT included cadaver specimens (2932) . In the present study, the male patients had a higher average bone density value at the implant sites than that in female patients (the mean of average bone density of all implant recipient sites was (541229 HU in males; while in females 378123 HU), there was a statistically higher significant difference in the average bone density of implant sites between males and females. This finding may be explained with the hormonal peculiarities in females and generally higher bone mass in males. Previous studies
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including the measurement of the bone mineral contents in the jaws and forearms have already indicated that, when compared to the males, lower bone mineral densities in females have been found throughout adult life (33). However, this finding is in agreement with (28,34). In the present study, the difference in the average bone density of the implant recipient sites between the mandibles (581202 HU) and the maxillae (33880 HU) was statistically of high significance for all patients, this finding is in agreement with (35), who reported that the difference in the average bone density of the implant sites between the mandibles (828 245 HU) and the maxillae (582 192 HU) was statistically significant for all patients. The mean bone densities recorded in this study are lower than those reported by (35, 36) table (1), which might be due to the previous measurements including the trabecular bone and the outer cortical shell. The density of cortical bone is significantly higher than that of trabecular bone. However, we observed higher mean bone densities than did (37), which might be due to the use of different types of software. In the two studies de-Oliveira et al indicated that this could yield different bone density values from the same CT images. In addition, the ranges of the mean bone density in the present study are broadly consistent with those of (38, 39) table (5). The differences between the present study and the previous studies come from the distribution of implant recipient sites. Because the effect of number of implant sites in region was neglected in previous studies. As the bone is reduced in volume to C shape minus height (C-h), especially in the anterior mandible. The C-h mandible often exhibits an increase in torsion or flexure in the anterior segment between the mental foramens during function. This increased strain causes the bone to increase in density (40). In this study and all previous studies was found that most density was in the anterior mandible (35-39). The bone density recorded in the present study were (68298 HU, 481104 HU, 41392 HU, and 26367 HU) values in the anterior mandible, followed by the posterior mandible, anterior maxilla, and posterior maxilla, respectively. Shapurian et al. (38) found that the mean bone density was lower in the posterior mandible than in the posterior maxilla (in contrast to the results of the present study). These discrepancies might have resulted from the distribution of implant recipient sites, because a relatively high number

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of their implant recipient sites were in the posterior mandible which has the lowest bone density values. In this study, it has been observed that the average bone density value of the implant sites in the anterior regions of jaws was higher than that in the posterior regions (anterior mandible posterior mandible; anterior maxillaposterior maxilla). This finding is in conformity with those reported by (35-39). In the present study there is no significant difference in the mean bone density between the anterior maxilla and the posterior mandible in females, while in males there was a statistically significant between the posterior mandible and the anterior maxilla. This finding is partially in agreement with (35); stated that there are differences in the average bone density of the implant sites that was not statistically significant between the posterior mandible and the anterior maxilla. Insertion torque The insertion torque is the latest value seen on the screen was recorded. Starting from 20Ncm, the insertion torque was increased in steps of 5Ncm, when the rotation stopped due to friction before the implant was fully inserted. Only a limited amount of torque could be applied in order to avoid mechanical overload of the equipment on bone tissue. Statistically significant strong correlations between bone density and insertion torque were found at implant placement. This fact concurs with the previous studies (36, 39, 41, 42).

REFERENCES
1. Tolstunov L. Implant zones of the jaws: implant location and related success rate. J Oral Implantol 2007; 33:21120. 2. Ozan O, Turkyilmaz I, Yilmaz B. A preliminary report of patients treated with early loaded implants using computerized tomography-guided surgical stents: flapless versus conventional flapped surgery. J Oral Rehabil 2007; 34:83540. 3. Fyhrie DP. SummaryMeasuring bone quality. J Musculoskelet Neuronal Interact 2005; 5:318320. 4. Shapurian T, Damoulis PD, Reiser GM, Griffin TJ and Rand WM. Quantitative evaluation of bone density using the Hounsfield index. Int J Oral Maxillofac Implants 2006; 21:2907. 5. Lekholm U and Zarb GA. Patient selection and preparation. In: Branemark PI, Zarb GA, Alberktsson T, eds. Tissue integrated prostheses: osseointegration in clinical dentistry. Chicago: Quintessence 1985;1985:199209. 6. Hounsfield GN. Computerized transverse axial scanning (tomography). 1. Description of system. Br J Radiol 1973; 46:101622. 7. Homolka P, Beer A, Birkfellner W, Nowotny R and Gahleitner A. Bone mineral density measurement

with dental quantitative CT prior to dental implant placement in cadaver mandibles: pilot study. Radiology 2002; 224:24752. 8. Chen WP, Hsu JT and Chang CH. Determination of Youngs modulus of cortical bone directly from computed tomography: a rabbit model J Chin Inst Eng 2003; 22:1218. 9. de Oliveira RC, Leles CR, Normanha LM, Lindh C. and Ribeiro- Rotta RF. Assessments of trabecular bone density at implant sites on CT images. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105:231 8. 10. Norton MR and Gamble C. Bone classification: an objective scale of bone density using the computerized tomography scan. Clin Oral Implants Res 2001; 12:7984. 11. Turkyilmaz I, Tozum TF and Tumer C. Bone density assessments of oral implant sites using computerized tomography. J Oral Rehabil 2007; 34:26772. 12. Iwashita Y. Basic study of the measurement of bone mineral content of cortical and cancellous bone of the mandible by computed tomography. Dentomaxillofac Radiol 2000; 29:20915. 13. Loubele M, Maes F, Schutyser F, Marchal G, Jacobs R and Suetens P. Assessment of bone segmentation quality of cone-beam CT versus multislice spiral CT: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 102:22534. 14. Shahlaie M, Gantes B, Schulz E, Riggs M and Crigger M. Bone density assessments of dental implant sites: 1. Quantitative computed tomography. Int J Oral Maxillofac Implants 2003; 18:22431. 15. BouSerhal C, Jacobs R, Quirynen M and van Steenberghe D. Imaging technique selection for the preoperative planning of oral implants: a review of the literature. Clin Implant Dent Relat Res 2002; 4:15672. 16. Turkyilmaz I, Tozum TF, Tumer C and Ozbek EN. Assessment of correlation between computerized tomography values of the bone, and maximum torque and resonance frequency values at dental implant placement. J Oral Rehabil2006; 33:8818. 17. Turkyilmaz I and McGlumphy EA. Is there a lower threshold value of bone density for early loading protocols of dental implants? J Oral Rehabil2008; 35:77581. 18. Wagner W, Esser E, Ostakamp K. Osseointegration of Dental Implant in Patients with and without Radiotherapy. Acta Oncol 1998; 37(7-8):693-6. 19. Harry D and Ogle OE. Atlas of Minor Oral Surgery. Text book, Mosby Company 2001; p219-41. 20. Jeffcoat MK. The association between osteoporosis and oral bone loss. J Periodontol 2005; 76(11):21, 2532. 21. Jaffin RA & Berman CL. The excessive loss of Branemark fixtures in type IV bone: a 5-year analysis. J Periodontol 1991; 62:24. 22. Johns RB, Jemt T, Heath MR, Hutton JE, McKenna S & McNamara DC. A multicenter study of over dentures supported by Branemark implants. Int J Oral Maxillofac Implants 1992; 7:51322. 23. Lazzara R, Siddiqui AA, Binon P, Feldman SA, Weiner R & Phillips R. Retrospective multicenter analysis of 3i endosseous dental implants placed over a five-year period. Clin Oral Implants Res 1996; 7:7383.

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24. Schenk RK & Buser D. Osseointegration: a reality. Periodontol1998; 17:2235. 25. Tolstunov L. Implant zones of the jaws: implant location and related success rate. J Oral Implantol 2007; 33:21120. 26. Schwarz M. S, Rothman SLG, Rhodes M L & Chafetz N. Computed tomography: part I. Preoperative assessment of the mandible for endosseous implant surgery. Intern J Oral and Maxillofacial Implants1987; 2: 13741. 27. Beer A, Gahleitner A, Holm A, Tschabitscher M & Homolka P. Correlation of insertion torques with bone mineral density from dental quantitative CT in the mandible. Clinical Oral Implants Res 2003; 14:61620. 28. Ikumi N & Tsutsumi S. Assessment of correlation between computerized tomography values of the bone and cutting torque values at implant placement: a clinical study. International Journal of Oral and Maxillofacial Implants 2005; 20: 25360. 29. Shahlaie M, Gantes B, Schulz E, Riggs M & Crigger M. Bone density assessments of dental implant sites: 1. Quantitative computed tomography. Intern J Oral and Maxillofacial Implants2003; 18:224231. 30. Fanuscu MI & Chang TL. Three dimensional morphometric analysis of human cadaver bone: microstructural data from maxilla and mandible. Clinical Oral Implants Res 2004; 15: 2138. 31. Hanazawa T, Sano T, Seki K & Okano T. Radiologic measurements of the mandible: a comparison between CT-reformatted and conventional tomographic images. Clinical Oral Implants Res 2004; 15: 22632. 32. Aranyarachkul P, Caruso J, Gantes B, Schulz E, Riggs M, Dus I, Yamada JM & Crigger M. Bone density assessments of dental implant sites: 2. Quantitative cone-beam computerized tomography. Intern J Oral and Maxillofacial Implants 2005; 20: 41624. 33. Von Wovern N, Westergaard J & Kollerup G. Bone mineral content and bone metabolism in young adults

with severe periodontitis. J Clin Periodontol 2001; 28:5838. 34. Turkyilmaz I, Tozum TF and Tumer C. Bone density assessments of oral implant sites using computerized tomography. J Oral Rehabil 2007a; 34:26772. 35. Turkyilmaz I, Tumer C, Ozbek EN & Tzm TF. Relation between the bone density values from computerized tomograghy, and implant stability parameters: a clinical study of 230 regular platform implants. J Clin periodontal 2007b; 34: 716-22. 36. Turkyilmaz I & Mcglumphy E. Is there a lower threshold value of bone density for early loading protocols of dental implants? J Oral Rehab 2008; 35:775-81. 37. de Oliveira RC, Leles CR, Normanha LM, Lindh C & Ribeiro-Rotta RF . Assessments of trabecular bone density at implant sites on CT images. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105:231 8. 38. Shapurian T, Damoulis PD, Reiser GM, Griffin TJ & Rand WM. Quantitative evaluation of bone density using the Hounsfield index. Int J Oral Maxillofac Implants 2006; 21:2907. 39. Fus H, Chen K, Shen M, Shen T & Hsu J. Variations in bone density at dental implant sites in different regions of the jawbone. J Oral Rehab 2010; 2:121-32. 40. Misch CE. Early crestal bone loss etiology and its effect on treatment planning for implants. J postgred Dent 1995; 2(3):3-17. 41. Turkyilmaz I, Sennerby L, Tumer C, Yenigul M, Avci M. Stability and marginal bone level measurements of un splinted implants used for mandibular overdentures. A one-year randomized prospective clinical study comparing early and conventional loading protocols. Clin Oral Implants Res 2006a; 17:501505. 42. Turkyilmaz I, Tozum TF, Tumer C & Ozbek EN. Assessment of correlation between computerized tomography values of the bone, and maximum torque and resonance frequency values at dental implant placement. J Oral Rehabilitation 2006b; 33:8818.

Table 1: Comparison of BD and torque in males and females at level (p <0.01).


Males and t Sig. females 4.840 0.0005 BD Torque 4.364 0.0005

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

Table 3: Comparison of BD and torque in mandibles and maxillae at level (p <0.01).


Maxilla & Mandible BD torque Oral Diagnosis t-test for Equality of Means t Sig. 8.62 0.0005 8.01 0.0005 60

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Table 4: Correlation between BD and torque in Maxilla & Mandible at the (p<0.01) level.
Maxilla & Mandible BD Pearson correlation Sig. N. torque 0.938 0.0005 120

Table 5: Reference that shows bone densities in different regions of the jawbone [expressed in Hounsfield units (HU); numbers within parentheses are sample sizes]
Anterior mandible Region Posterior mandible Anterior maxilla Posterior maxilla

Shapurian et al. 559208(42) 3211132(78)517177(45) 333119(54) (2006) Turkyilmaz et al. 945207(58) 674227(28) 716190(28) 455122(21) ( 2007a) Turkyilmaz& 846234(100) 526107(60) 591176(70) 40395(70) Mcglumphy (2008) de-Oliveira et al. 383243(6) 306187(28) 370176(6) 255184(29) (2008) Fus et al. (2010) 530161(15) 359150(55) 516132(47) 332136(37) 68298(30) 481104(30) 41392(30) 26367(30) This study

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Evaluation of oral health status in a sample of autistic male children


Mayyadah H. Rashid, B.D.S., M.Sc.(1) Raja H. Al-Jubouri, B.D.S., M.Sc., Ph.D. (2)

ABSTRACT
Background: Autism is a severe neurodevelopmental disorder, presents in early childhood, characterized by severe impairments in socialization, communication and behavior. Autism is considered a multi-factorial disorder that is influenced by genetic, environmental, and immunological factors with oxidative stress as a mechanism linking these factors. Assessment of any oral manifestations has to be discovered, evaluated and measured in autistics to be used as a potential diagnostic. Materials and methods: Oral health status:(DMFT) for permanent teeth, (dmft)for deciduous teeth and gingival indices were estimated for 58 individuals aged (2-13) years, twenty nine of them were autistics and twenty nine were sex and age matched healthy controls. Results: The results of this study showed that Iraqi autistic children sample was more likely to be caries-free compared with healthy sample. Conclusion: Children with autism spectrum disorder (ASD) were more likely to be caries-free, had lower DMFT\ dmft and GI scores than did their unaffected peer and can be used in autism spectrum disorder prediction to a limited extent. Key words: Autism spectrum disorder; Oral health status. (J Bagh Coll Dentistry 2012;24(2):62-65).

INTRODUCTION
Autism spectrum disorders (ASDs) are prevalent 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, communication 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 comorbidity conditions often associated with ASDs include gastrointestinal and autoimmune disease (3) . Investigators suggested that ASDs may result from an interaction between genetic, environmental and immunological factors, with oxidative stress as a mechanism linking these risk factors (4). Oral health and dental needs of children withautism have been evaluated by very few investigators. The studies conducted on this topic reported nostatistically significant differences in the prevalence of caries, fillings, gingivitis and degree of oral hygiene in comparison with nonautistic individuals8, and even a lower incidence of caries in some of the reports(5).

Given the well-established fact that mercury (Hg) is known to significantly increase oxidative stress and that fetuses and infants are routinely exposed to Hg from environmental sources (fish, dental amalgams, etc.), investigators have described that many ASDs may result from a combination ofgenetic/biochemical susceptibility, specifically areduced ability to excrete Hg, and exposure to Hg at critical developmental periods.Further, it was reported that Hg can cause immune, sensory, neurological, motor, and behavioraldysfunctions similar to traits defining/associated with ASDs, and that these similarities extend to neuroanatomy, neurotransmitters, and biochemistry. Also, it was reported when reviewing the molecular mechanisms of Hg intoxication that it can induce death, disorganization and/or damage to selected neurons in the brain similar to that seen in recent ASD brain pathology studies, and this alteration may likely produce the symptoms by which ASDs are diagnosed(6).

MATERIALS AND METHODS


Sixtyindividuals from Central Pediatric Teaching Hospital in Al-Iskanwere 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 ages range between 2-13 years. Because the female sample very small, it was excluded from the current study. Healthy control group: Composed of 29 age and gender matched male children.

(1) (2)

M.Sc. Oral medicine, Specialist in Ministry of Health. Professor, Department of Oral Diagnosis , College of Dentistry, Baghdad University

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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 wereexplained to them.All the children subjected to extra-oral examination for any scars or trauma to the head, neck, hands and fingers; taking 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 (7). All data were statistically analyzed using SPSS version 13 (Statistical Package for Social Sciences). Non-normally distributed quantitative variables (DMFT\dmf score) are described by median and interquartile range. The remaining quantitative variables (age 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.

According to 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). Tables2 and 3 summarize an assessment of DMFT, dmft and GI scores among the study subjects with ASD in comparison to the controls.Table 4 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 developmental 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 (8,9). 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, Alzheimersdisease, mental disorder and depression(10). In the present study 28 children (96.6%) had never visited dental clinic or received dental treatment and follow upand this could be explained by the fact that people with ASD incapable of cooperating in the dentalsetting owing to their impaired social interaction and communicationskills. In addition to cognitive dysfunction, aggression and other associated psychiatric symptoms may impede the provision of dental care. This result was in good agreement with many studies (11-14). 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 behaviorwhich characterized by unvarying pattern of daily activities, such as an unchanging menu so they are moreregular in their behavior at meals than are unaffected children.Therefore, a lower frequency of snacking between meals and lowerintake of carbohydrates could have contributed to the lowercaries rate observed and this finding agreed with several studies (9, 15) .While disagreed with others who reported
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RESULTS
The mean age for autistic children was about 5.93.4 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 as shown in table (1). Intra Oral Examination: The caries severity of children in the ASD group was statistically significantlower 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%) childrenin the ASD group had a positive caries free history (DMFTand dmft=0), compared with9 (31%) children in healthy control group.

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higher scores in autistic groups (5, 16). Caries prevalence lower in autistic children participating in the present study and this result were in good agreement with many previous studies (9, 5). Gingival status of the autistic children in the present study showed that (96,6%) of the children had generalized mild gingivitis, which it was in good agreement with many previous studies (5,16). While Ozdemir-Ozenenand Sandalli, 2007 (17), in their study reported that the gingival index records of the children with autism was found to be significantly higher than the healthy children. All these findings could be related to many reasons such as the irregular brushing habits because of the difficulties the trainers and the parents encountered when they brushed the children's teeth. It could also be due to lack of the necessary manual dexterity of autistic children during brushing by themselves, which made their tooth brushing inefficient. Furthermore, the findings of this study reflect poor dental awareness, a lack of dental education and deficiency in receiving oral hygiene instructions from dental staff. Care-givers need to know the different techniques and materials of tooth brushing with emphasis on behavior modification to control the behavior of the children and regular dental visits. In the present study, aim was directed to assess and measure 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 oral health status as diagnostic aid through measuring the DMFT, dmft and GI under condition of stress due to autism in a sample of Iraqi autistics. The ROC test results of this study revealedthat the areas under ROC curve for DMFT (0.521) was not significantly different from 0.5 value of an equivocal test (p = 0.79).And for dmft was significantly higher (0.669) from 0.5 value of an equivocal test (p = 0.027). ), while the areas under ROC curve for GI was higher (0.669) from 0.5 value of an equivocal test, but statistically insignificant (p = 0.11).So dmft ranked number onefollowed by GI then DMFT as ranked third in order of importance in this study as shown in table (3).

REFERENCES
1. 2. Newschaffer CJ, Croen LA, Daniels J et al. the epidemiology of autism spectrum disorders. Annu Rev Public Health 2007; 28:23558. Austin D. An epidemiological analysis of the autism as mercury poisoning hypothesis. International Journal of Risk and Safety in Medicine 2008; 20:13542. Geier, Kern, Geier. A prospective study of oxidative stress biomarkers in autistic disorders. Electronic J Applied Psychology 2009; 5(1): 2-10. 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 inchildren with autism. American Journal of Medical Genetics, Part B: Neuropsychiatric Genetics 2006; 141: 947-56. 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. Geier DA, King PG, Sykes LK, & Geier MR. A comprehensive review of mercury provoked autism. Indian J Medical Res 2008; 128: 383-411. Silness J, Le H. Periodontal disease in pregnancy II correlation between oral hygiene and periodontal condition. ACTA OdontolScand 1963; 22:121-135. 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 DevDisabil 2007; 28(2):14562. 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. Freitag CM. The genetics of autistic disorders and its clinical relevance: a review of the literature. Mol Psychiatry 2007; 12(1):222. 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):116775. Friedlander AH, Yagiela JA, Paterno VI, Mahler ME. The neuropathology, medical management and dental implications of autism. JADA 2006; 137(11):1517 27. Marshall J, Sheller B, Williams BJ, Mancl L, Cowan C. Cooperation predictors for dental patients with autism. Pediatr Dent 2007; 29 (5): 36976. Pilebro C, Backman B. Teaching oral hygiene to children with autism. Int J Paediatr Dent 2005; 15 (1):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):85566. De Mattei R, Cuvo A, Maurizio S. Oral assessment of children with an autism spectrum disorder. Journal of Dental Hygiene 2007; 81: 3. zdemirzenen D, ldr K, Sandall N. The oral health status of children with visual impairment. 12th Congress of the BaSS, stanbul, Trkiye; 2007.P.1214.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

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Table 1: Extra-oral examination and case history of autistics


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

Table 2:MeanSD for tested parameters


Markers Gingival index Cases 0.55 0.35 Controls 0.750.48 p 0.08 [NS]

Table 3: Median level for selected parameters


Markers DMF dmf Cases 0 0 Controls 0 1 p 0.73[NS] 0.013

Table 4: ROC analysis of testedparameters


parameters dmf Gingival index DMF Area under the curve 0.669 0.622 0.521 P 0.027 0.11[NS] 0.79[NS]

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Ovulation detection through salivary levels of sialic acid and glycosaminoglycans


Rand M. Al-khafagy, B.D.S., M.Sc. (1) Sahar H. Al-Ani, B.D.S., M.Sc. (2) Ali Y.Majid, M.B.ch.B., M.Sc., F.I.C.M.S. (3)

ABSTRACT
Background: One in ten couples of reproductive age encounter some level of infertility. Identification of the period of ovulation in humans is critical in the treatment of infertility. Success in in vitro fertilization and embryo transfer has been associated with the exact time of ovulation. Saliva is a unique diagnostic fluid, the composition of which immediately reflects the sympathetic nervous system, parasympathetic nervous system, hypothalamic- pitutaryadrenal axis and immune system response to stress. The study aims at evaluating the changes in salivary sialic acid and Glycosaminoglycans in the regular menstrual cycle. Thus, the presence of these carbohydrates in the ovulatory saliva makes the possibility to develop a biomarker for the detection of ovulation by noninvasive methods. Subjects, materials and methods: Randomly, seventy five volunteer females were recruited and divided into 5 groups; each contains 15 subjects as follow: Nine years old females and postmenopausal females as control groups, pre-ovulatory period, ovulatory period and post-ovulatory period females as experimental groups. Each female, of the experimental groups, underwent sonographic examination to estimate her period regarding ovulation. Unstimulated whole saliva was collected using the spitting method. Colorimetric procedure was used for total sialic acid determination and for Glycosaminoglycans quantitative determination, the method of ELISA was used. Results: The concentration of sialic acid was significantly decreased in saliva of females in the ovulatory phase of the menstrual cycle; whereas, a significant increase in salivary sialic acid concentration was in the post-ovulatory phase. Glycosaminoglycan concentration showed a gradual increase from the pre-ovulatory phase then ovulatory to reach its maximum in the post-ovulatory phase with a significant difference between the pre-ovulatory and post-ovulatory phases. A significant correlation was not found between sialic acid and Glycosaminoglycans in different study groups. Conclusions: On the basis of the results arrived at, the study concluded that there are remarkable cyclic variations in sialic acid and glycosaminoglycans during the menstrual cycle but in conclusion, glycosaminoglycans and sialic acid salivary levels cannot be used for the precise prediction of ovulation. Keywords: Ovulation, saliva, sialic acid, glycosaminoglycans. (J Bagh Coll Dentistry 2012;24(2):66-69).

INTRODUCTION
The cyclic physiologic changes are mainly brought about by the ovarian hormones estrogen and progesterone, the levels of which show variation during the menstrual cycle. Identification of the period of ovulation in humans is critical in the treatment of infertility. Success in in vitro fertilization and embryo transfer has been associated with the exact time of ovulation. In the recent years, attention has been paid to the noninvasive method in ovulation detection (1). Saliva is a unique diagnostic fluid, the composition of which immediately reflects the sympathetic nervous system, parasympathetic nervous system, hypothalamic-pituitary-adrenal axis and immune system response to stress (2). Recent reports shows that the saliva is a very good source of both hormones and biochemicals and that their levels change in accordance with the menstrual cycle (1).

(1) Ministry of Health, Iraq. (2) Assistant Professor, department of Oral Medicine, College of Dentistry, University of Baghdad. (3) Chemical Pathology

Carbohydrates are the major diet for mammalian species. The nature of the feeding habit would have a major impact on the excretion of biomolecules. This may be the reason for a considerable release of carbohydrates in the saliva (3,4) . Most of the salivary proteins are glycoproteins. Sialic acid (SA) is one of the terminal sugars of salivary glycoproteins. It is an important structural component of salivary glycoproteins, enhancing bacterial aggregation as well as participating in the formation of the acquired pellicle and dental plaque (5). A previous study suggests that bovine submaxillary mucin has hydroxyl radical scavenging ability and the SA in mucin is an essential moiety to scavenge hydroxyl radicals and mucin synthesis is induced by oxidative stress (6). Proteoglycans are macromolecular components of the extracellular matrix that play various roles in normal cell physiology and in pathologic states (7). Modulation of proteoglycan turnover by follicular stimulating hormone (FSH) and luteinizing hormone (LH) is mostly related to the ovulatory process (8). A recent study suggests changes in salivary glycosaminoglycan (GAGs) and sialic
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acid that are parallel to the normal increases in serum estrogen levels that occur in normal menstrual cycle (1).

MATERIALS AND MEHODS


This is a cross-sectional study in which seventy five volunteer females were recruited and divided into 5 groups; each contains 15 subjects as follow: Group A: Eight to nine years old females represent the pre-pubertal period. (Control group) Group B: Reproductive age females in the preovulatory period. (Experimental group) Group C: Reproductive age females in the ovulatory period. (Experimental group) Group D: Reproductive age females in the postovulatory period. (Experimental group) Group E: Postmenopausal females (10-20 years after menopause). (Control group) Each female, of the experimental groups, underwent sonographic examination first to estimate her period regarding ovulation. Unstimulated whole saliva was collected using the spitting method (9) for 10 minutes. For total sialic acid determination, the colorimetric procedure was used and the optical density was read at 549 nm (540-555nm) and the concentration of sialic acid was calculated according to standard curve. For Glycosaminoglycans quantitative determination, the method of ELISA was used, the absorbance (OD value) was determined at wave length 540nm and the concentration of GAG was calculated according to standard curve.

menstrual cycle. In the experimental groups, the lowest salivary GAGs level was in the preovulatory phase compared to control groups followed by a gradual increase in the ovulatory phase and the peak level was in the post-ovulatory phase as shown in fig 2. A statistically significant difference was found between the pre-ovulatory phase GAGs level and the post- ovulatory phase level (p=0.013). Also the levels showed a high significant difference between the pre-ovulatory phase and the postmenopausal group (p=0.0001). No significant differences were found among the other groups.

DISCUSSION
Sialic acid According to this study, SA level in old age group (above 45) were almost similar to that of children (8-9 years old) and are also not far away from its level in young adult except for its level in the post-ovulatory phase. This means that salivary sialic acid concentrations are almost constant and not related to age. This is in accordance with another study that found similar SA concentration from birth to adulthood (10). Meanwhile, this result is a disagreement with two other studies (11, 12) that stated that SA in human unstimulated saliva was affected by age with a trend toward reduction in SA concentration with age. The result of this study is also a disagreement with Narhi et al. (13) who stated that the concentration of SA and salivary peroxidase was highest in the oldest age group. As mentioned, the results of the present study revealed low concentration of SA in the preovulatory phase saliva; this is in accordance with two old studies that had observed decreased concentrations of SA both in human cervical mucus (14), and human whole saliva in this phase (15) . Nadir concentration in the ovulatory phase was found in this study and this is in accordance with Moghissi and Syner (16). Then a sudden rise to peak in the post-ovulatory phase; this is probably due to consumption of SA from the blood by the cell membranes of the growing follicles where it predominates because SA is a monosaccharide component of cell membranes (17) , so the consumed SA in the pre-ovulatory and ovulatory phases is more than the produced or gained. After the rupture of the dominant follicle ovulation takes place, the SA will be redelivered to the blood and the extra consumption of SA will be stopped in this phase. The fluctuation in SA concentration in the blood will be reflected in saliva. The results of the present study disagreed with Calamera et al. (18)

RESULTS
Saliva sialic acid and GAGs concentrations were almost constant in different age groups and not related to age. In the experimental groups, salivary sialic acid level decreased in the pre-ovulatory phase compared to control groups. Nadir level was obvious in the ovulatory phase, and then a sudden rise was found in the postovulatory phase making the highest concentration. Fig 1. A high statistically significant difference between SA conc. in the ovulatory phase and the postovulatory phase (p= 0.001). Another high significant difference was found between the ovulatory phase and the prepubertal group (p=0.001). A higher significant difference was found between ovulatory and postmenopausal group (p=0.0001). The only non-significant value was between ovulatory and pre-ovulatory periods (p=0.973). Salivary GAGs in normal young women presented a biphasic pattern, with higher concentration values during the second half of the Oral Diagnosis 67

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who reported a peak in salivary SA concentrations in the pre-ovulatory phase and Alagendran et al. study (1) who reported a peak in salivary SA concentrations in the ovulatory phase. Glycosaminoglycans In the present study, GAG showed a comparable concentration in the ovulatory phase (0.4120.175) ng/ml, to that of the control groups ((0.4520.279) for the pre-pubertal group and (0.4450.041) for the postmenopausal group) with the peak GAG concentration in the post ovulatory phase. These results are so far away from Alagendran et al. (1) study, in which, the GAG content showed a distinct peak at ovulation. The present results are also a disagreement with Giampiero et al. (19), who stated that in the women with ovulatory cycles, plasma GAG levels differed significantly during menstrual cycle, with increased values at the periovulatory phase (3.5 ug/ml) with respect to the menstrual phase. Another study did not find consistent variations during the normal menstrual cycle (20). In contrast, a significant variation in the urinary GAG concentration during ovulation was reported by Carranco et al. (21), this peak of maximal GAGs concentration (106.7 46.2 micrograms/mL in urine) was noticed during the ovulatory phase. In this research, the peak GAG concentration is in the post ovulatory phase (0.558 0.218)ng/ml, this could be due to the release of follicular fluid with its GAG content after rupture of the follicle to the blood stream which will be reflected in saliva. Another possible cause to the reduced GAG concentration in the first half of the menstrual cycle, and its increase in the post-ovulatory phase is that heparenase enzyme (HSPE) is transiently induced by luteinizing hormone during the ovulatory process and may be down-regulated by the increasing progesterone levels in the luteal phase (22). On the basis of the results arrived at, the study concluded that SA and GAGs were probably brought under the influence of cyclic variation of ovarian hormones. There are remarkable cyclic variations in sialic acid and GAGs during the menstrual cycle but in conclusion, GAGs and sialic acid cannot be used for the precise prediction of ovulation.

3.

4.

5.

6.

7.

8.

9. 10.

11.

12.

13.

14.

15.

16.

17.

REFERENCES
1. Alagendran S, Archunan G, Velayutha S Prabhu, Enrique B, Orozco A and Rosalinda Guevara Guzman. Biochemical evaluation in human saliva with special reference to ovulation detection. Indian J dental Res 2010; 21(2):165-8. 2. Khaustova S, Shkurnikov M, Tonevitsky E, Artyushenko V, Tonevitsky A. Noninvasive

18.

19.

biochemical monitoring of physiological stress by Fourier transform infrared saliva spectroscopy. Analyst 2010; 135: 3183-92. Galef BG Jr, Smith MA. Susceptibility of artificially reared rat pups to social influences on food choice. Dev Psychobiol 1994; 27: 85-92. Rameshkumar K. Chemical characterization of Bovine (Bos Taurus) Urine with special reference to reproductive behavior. Ph.D Thesis. Tiruchirappalli, Tamil Nadu, India: Bharathidasan Uzniversity; 2000. Rudney JD. Does variability in salivary protein concentrations influence oral microbial ecology and oral health? Crit Rev Oral Biol Med 1995; 6: 343-367. Ogasawara Y, Namai T, Yoshino F, Lee MC, Ishii K. Sialic acid is an essential moiety of mucin as a hydroxyl radical scavenger. FEBS Lett 2007; 581: 2473-77. Bishop JR, Schuksz M, Esko JD. Heparan sulphate proteoglycans fine-tune mammalian physiology. Nature 2007; 446: 1030-7. Richards JS.Ovulation: new factors that prepare the oocyte for fertilization. Mol Cell Endocrinol 2005; 234(1-2): 75-9. Navazesh M. Methods for collecting saliva. Ann N Y Acad Sci 1993; 20: 72-7. Tram T H, J C Brand Miller, Y McNeil, P McVeagh. Sialic acid content of infant saliva: comparison of breast fed with formula fed infants Archives of Disease in Childhood 1997; 77: 315-8. Salvolini E, Mazanti L, Martarelli D, Di Giorgio. Changes in the composition of human unstimulated whole saliva with age. Aging (Milano) 1999; 11(2):119-22. Dezan CC, Nicolau J, Souza DN, Walter LRF. Flow rate, amylase activity, and protein and sialic acid concentrations of saliva from children aged 18, 30 and 42 months attending a baby clinic. Archives of Oral Biology 2002; 47(6): 423-7. Narhi Timo O, Tenovuo J, Ainamo A, Vilja P.Antimicrobial factors, sialic acid and protein concentration in whole saliva of the elderly. J Dent Res 1994; 102: 120-5. Carlborg L, Johansson ED, Gemzell C. Sialic acid content and sperm penetration of cervical mucus in relation to total urinary oestrogen excretion and plasma progesterone levels in ovulatory women. Acta Endocrinol (Copenh) 1969; 62: 721-31. Oster G, Yang SL. Cyclic variation of sialic acid content in saliva. Am J Obstet Gynecol 1972; 15: 1903. Moghissi KS, Syner FN. Cyclic changes in the amount and sialic acid of cervical mucus. Int J Fertil 1976; 21: 246-50. Rudong Xing, Yuzhuo Zhang, Zhisan Wang, Ruimei Chen. Serum sialic acid level in patients with oral and maxillofacial malignancy. J Oral maxillofacial Surgery 1991; 49: 843-7. Calamera JC, Vilar O, Nicholson R. Changes in sialic acid concentration in human saliva during the menstrual cycle. Int J Fertil 1986; 31(1):43-5. Giampiero Capobianco, De Muro Pierina, Cherchi Gian Mario, Formato Marilena, Lepedda Antonio Junior, Cigliano Antonio et al. Plasma levels of Creactive protein, leptin and glycosaminoglycans during spontaneous menstrual cycle: differences between

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ovulatory and anovulatory cycles. Educus 2010; 282(2): 207-13. 20. Erickson DR, Ordille S, Martin A, Bhavanandan VP. Urinary chondroitin sulfates, heparan sulfate and total sulfated glycosaminoglycans in interstitial cystitis. J Urol 1997; 157: 61-4 21. Carranco A, Reyes R, Huacuja L, Guzmn A, Delgado NM. Human urinary glycosaminoglycans as accurate

method for ovulation detection. Int J Fertil 1992; 37: 209-13. 22. Eyal Klipper, Ehud Tatz, Tatiana Kisliouk, Israel Vlodavsky, Uzi Moallem, Dieter Schams,Yaniv Lavon, David Wolfenson, and Rina Meidan. Induction of Heparanase in Bovine Granulosa Cells by Luteinizing Hormone: Possible Role during the Ovulatory Process. Endocrinology 2009; 150: 413-21.

Figure 1: Saliva SA level in Control and Experimental Groups (mean SD)

Figure 2: Saliva GAGs level in control and experimental groups (mean SD) No significant correlation was found between SA and GAGs in all the study groups.

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Temporomandibular disorders in association with stress among students of sixth grade preparatory and students of fifth year high schools
Toka T. Alnesary, B.D.S. (1) Rafil H. Rasheed, B.D.S., M.Sc. (2)

ABSTRACT
Background: A close relationship had been reported between depression, anxiety and many disease symptoms or disorders. This is true for temporomandibular disorders which is a collective term embracing a number of clinical problems that involve the masticatory musculatures, temporomandibular joint and associated structures, or both. This study designed to evaluate the association of stress with temporomandibular disorders among sixth grade preparatory students and students of fifth year of secondary school. Subjects, materials and methods: The sample's size of 404 students of sixth grade preparatory study (154males and 250 females) and 360 (168males and 192females) of fifth year of secondary schools. Firstly all the students subjected for stress questionnaire, secondly the stressful students subjected to different combination of clinical and questionnaire measures according to the research diagnostic criteria of temporomandibular disorders (axis I) which have standardized series of diagnostic tests based on clinical signs and symptoms. Data are analyzed by using Z-test and chi-square. Results: The results obtained from this study showed that no significant differences between classes in the percentage of stressful students with temporomandibular disorders according to the clinical examination but in both classes, females' students showed higher percentage of temporomandibular disorders than males of same class. Bruxism and nail biting were significantly higher among students of sixth grade. Conclusions: This study revealed that stress of studying at sixth grade has no effect on temporomandibular disorders prevalence. Keywords: Stress, temporomandibular disorders, myofascial. (J Bagh Coll Dentistry 2012;24(2):70-74).

INTRODUCTION
Temporomandibular joint (TMJ) should not be isolated or excluded from being associated with other joints disorders but fortunately the temporomandibular disorders (TMDs) could be an early exploration to other joint disorders1 Temporomandibular disorders are a collection of disorders involving the temporomandibular joint, the soft tissue structures within the joint, and the muscles of mastication 2. The etiology of these disorders is multidimensional. Biomechanical, neuromuscular, biopsychosocial, and neurobiological factors may contribute to TMDs 3. These factors are initiating and aggravating (parafunctions, hormonal, or psychosocial factors) to emphasize their role in the progression of TMD 4. Some studies revealed that occlusal factors were only weakly associated with TMD signs and symptoms 5, 6. Moreover, there are people classified as bruxers, who did not present history of pain in masticatory muscles 7, 8. There is currently considerable evidence that psychological factors are of importance in the understanding of TMD.

Research findings have supported a relationship between anxiety, muscular tension, and TMD symptoms, the psychological status assessment showed that 39.8% of patients with TMD experienced moderate to severe depression, and 47.6% had moderate to severe nonspecific physical symptom scores (somatization) 9. The importance of psychological factors in the etiology of TMD has usually been emphasized; they are believed to predispose the individual to chronicity 10. Temporomandibular disorders are often associated with somatic and psychological complaints, including fatigue; sleep disturbances, anxiety, and depression 9, 11. Thus, considering that stress is associated with psychological disturbances such as anxiety and depression 12.

MATERIALS AND METHODS


This study was carried out in randomly selected secondary schools of Baghdad city for evaluation the association of stress with TMDs in students according to the research diagnostic criteria of TMD (RDC/TMD axis I). The sample's size of 404 students of sixth grade preparatory study (154 males and 250 females) and 360 (168 males and 192 females) of fifth year of secondary schools.
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(1) M.Sc. Oral Medicine, Ministry of Health, Iraq. (2) Professor, Dean of College of Dentistry, University of AlAnbar, Iraq

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Subjects gave their informed consent and the local ethical committee approval. The students subjected for stress questionnaire which consist of 20 questions a score of 7 or more is considered positive for a potential psychiatric problem. Then the stressful students subjected to different combination of questionnaire and clinical measures according to RDC/TMD (Axis I). The stressful students whom subjected to clinical examination had no history of head injury and without orthodontic treatment, dental pain, muscle tenderness due to systemic diseases as fibromyalgia, neuralgia or local infection and had no more than 2 missing posterior teeth. The stressful students who had pain in the face, jaw, temple, priauricular or in the ear and headaches or migraine or pain that limit these activities: chewing, exercising, eating hard or soft food or drinking, smiling, oral hygiene, yawning and talking and those who had clicking, bruxism and oral habit were asked about: the pain history with conformation of pain location plus palpation of masticatory muscle sites, results in report of familiar pain13, and asked about jaw locking or catching that interfere with eating The students with positive answer subjected to clinical examination, these include ear examination, cervical examination, and determination of masticatory muscles pain during active mouth opening (un-assisted mouth opening) and passive mouth opening (assisted mouth opening).This accomplish by Palpation the TMJ (lateral pole) during opening and closing three times at least to detection the joint sound. Then determination of masticatory muscles and TMJ pain during excursive movement of mandible, with determination of joint sound on excursive movement of mandible by stethoscope placed on lateral pole of TMJ 14 Tenderness of TMJs needs to be palpated in three locations. Tenderness in one of these locations is not necessarily associated with tenderness in another. Pain or tenderness can occur in static position or during opening and closing the mouth. palpation of the first location by asking the patient to open approximately 20 mm and palpating the condyles lateral pole, then by asking the patient to open as wide as possible while palpating the depth of depression behind the condyle with fingertip, finally with the finger in the depression and the mouth open wide, by pulling forward to load the posterior aspect of the condyle via external auditory meatus using the small finger.
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The patients were asked about any bad oral habits with observation their evidences.

RESULTS
There were significant differences between classes in percentage of stressful students by selfreport stress,. In this study from all selected males of fifth year there were 21 (12.5%) stressful students and from selected females of fifth year there were 117(60.9%) stressful students, so the total number of stressful students in the fifth year of secondary study was 138 (38.3%) from 360 students were subjected to self report questionnaire, while in the six grade of secondary study the percentage of stressful students were higher than those in fifth year as follow: stressful males were 62(40.3%) and 214 (85.6%) stressful females, so the total number of stressful students in sixth grade was 276 (68.3%) These findings were listed in table (1). But there were no significant differences between classes in percentage of stressful students had TMDs according to the clinical examination, In this study from all selected students of fifth year there were 10 (5.9%) males and 45(23.4%) females had TMD by clinical examination, so the total number of the stressful students with TMDs by clinical examination in the fifth year of secondary study was 55 (15.2%) which was less than students in the six grade where TMDs showed 63(15.5%) which divided into 12 (7.7%) males and 51 (20.4%) females, and these findings were listed in table (2). The number of students in the fifth year who had myofascial pain (and some of them had MFP in combination with other TMDs) was (52), which was more than those in sixth grade (48) and the differences were significant, while the disc displacement with reduction was (6), the disc displacement without reduction was (6) and arthralgia also was (6) presented in less numbering the students of fifth year in comparison to those of sixth grade (8,15,12) respectively but the differences were not significant. It had been found that percentage of sixth grade students with deflection (57.1%) was higher than that in the fifth class students (50.9%), and the percentage of sixth grade students with nail biting (34.9%) was higher than that in the fifth class students (9.1%) with significant differences.

DISCUSSION
This study revealed that most of students in the secondary school were under stress and the differences were highly significant (P value =

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0.001) between fifth (38.3%) and sixth grades (68.3%). Yusoff et al., 201115 in previous study found that the prevalence of distressed secondary school students in Malaysia was 32.8%. Other previous studies reported that over one-third of adolescents were under stress 16, 17. Many of these emotional disturbances seem to be caused by school-related stress such as inappropriate workloads or assignments, examinations, falling behind compared to others and inappropriate treatment by teachers 16 Several authors have observed that the prevalence of psychological distress is higher among students than among working nonstudent populations of the same sex and age 18 By clinical examination it had been shown that the prevalence of TMDs in stressful students of fifth and sixth year of secondary study was nearly equal (15.2%, 15.5%), although the percentage of stressful students in sixth grade was significantly higher. This percentage was lower than that observed in another studies 19, 20, 21 and showed agreement with similar result reported by 22, 23.The large frequency ranges for signs and symptoms of TMD previously described in reviews are apparently based on very different samples (e.g. random , non-random, different ages, age ranges, sample size, ratio of gender distribution) and different examination methods (e.g. kind of variable, method of data collection) 24. The role of stress and personality in the etiology of the temporomandibular pain dysfunction syndrome has undergone extensive scrutiny. There is considerable evidence that psychological and psychosocial factors are of importance in the understanding of TMD as with other chronic pain disorders 25 but there is less evidence that these factors are etiologic. Even though studies have indicated the role of stress in the etiology of TMD, the issue of whether psychological factors cause TMD or reflect the impact o TMD on the person remains unknown, due largely to the absence of longitudinal incidence studies designed to test the relationship of the onset of TMD pain to the onset of psychological and psychosocial factors. Several studies have assessed the relationship between TMD and stress, these studies have had shortcomings, e.g., assessment of acute stress, limited sample size, nonstandardzed examination, no controls12, 26, 27 Although some reports noted no sex differences in the prevalence of TMD 20, 23, this has not been the case for some of the signs and symptoms in the present study. Generally females have more signs and symptoms than males. This
Oral Diagnosis 72

is in agreement with other reports in the literature 28, 29 .It has been stated that these sex differences could probably be explained by mental factors i.e. young females seem to present a lower pain threshold 28. Kuttilla et al., found that females showed more signs and symptoms of TMD, and it seems to be explainable by their higher stress. The higher prevalence of TMD in females than in males has been attributed to an interaction of a variety of factors ranging from biological and hormonal factors to psychological and social ones. In this study the students who were recorded with myofascial pain more than students with other TMDs even those students with MFP alone or in combination with other TMDs. Lobbezoo et al., (2004) revealed that between 50% and 70% of all patients with TMDs reported masticatory muscle pain, Deflection (57.1%, 50.9%) and midline deviation (58.7%; 61.8%) were reported in both sixth class and fifth class respectively, which were higher than that observed by other study (Feteih, 2006). Several studies failed to find strong evidence to support the theory that occlusion plays a role in the etiology of TMD, particularly as the sole cause or the dominant factor 32, 33. While Gesch et al., (2004) reported a weak association between malocclusion and the functional and clinical parameters of occlusion as well as subjective TMD. Oral habits (nail biting) was also reported in this study and showed higher percentage among students of sixth (34.9%) than students in the fifth class (9.09%) with significant difference. Other study reported lower percentage than that of students in sixth class 20. The higher frequency of nail biting that had been recorded at clinical examination may explain the higher percentage of students at sixth class with disc displacement without reduction, arthralgia and disc displacement with reduction. There is currently considerable evidence that psychological factors are of importance in the understanding of TMD. The issue of whether psychological factors cause TMD or reflect the impact of TMD on the person remains unknown, although there is strong evidence that some patients with TMD are more anxious and/or depressed compared with asymptomatic controls. Research findings have supported a relationship between anxiety, muscular tension, and TMD symptoms 35.

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REFERENCES
1. Martin S, Michael Glick, Jonathan A. Oral medicine, Diagnosis and treatment. 11th ed. BC Decker Inc; 2008. p.243. 2. Leeuw De R. Internal derangement of the temporomandibular joint. Oral Maxillofac Surg Clin North Am 2008; 20:159-68. 3. Suvinen TI, Reade PC, Hanes KR, Knnen M, Kemppainen P. Temporomandibular disorder subtypes according to selfreported physical and psychosocial variables in female patients:a reevaluation. J Oral Rehabil 2005; 32:166-73. 4. Neill Mc C. Management of temporomandibular disorders: concepts and controversies. J Prosthet Dent 1997; 77: 510-22. 5. Mohlin BO, Derweduwen K, Pilley R, Kingdon A, Shaw WC, Kenealy P Malocclusion and temporomandibular disorder: a comparison of adolescents with moderate to severe dysfunction with those without signs and symptoms of temporomandibular disorder and their further development to 30 years of age. Angle Orthod 2004; 74:31927. 6. Magnusson T, Egermarki I, Carlsson GE A prospective investigation over two decades on signs and symptoms of temporomandibular disorders and associated variables. A final summary. Acta Odontol Scand 2005; 63:99109. 7. Lavigne GJ, Kato T, Kolta A, Sessle BJ. Neurobiological mechanisms involved in sleep bruxism. Crit Rev Oral Biol Med 2003; 14:3046 8. Fujii T, Torisu T, Nakamura S. A change of occlusal conditions after splint therapy for bruxers with and without pain in the masticatory muscles. Cranio 2005; 23:1138. 9. Yap AU, Dworkin SF, Chua EK, List T, Tan KB, Tan HH. Prevalence of temporomandibular disorder subtypes, psychologic distress, and psychosocial dysfunction in Asian patients. J Orofac Pain 2003; 17:21-8. 10. Rollman GB, Gillespie JM. The role of psychophysiological factores in temporonandibular disorders. Curr Rev Pain 2000; 4:71-81. 11. Bonjardim LR, Gaviao MB, Pereira LJ, Castelo PM. Anxiety and depression in adolescents and their relationship with signs and symptoms of temporomandibular disorders. Int J Prosthodont 2005; 18:347-52. 12. Gameiro GH, da Silva Andrade A, Nouer DF, Ferraz de Arrude Veiga MC. How many stressful experiences contribute to the development of temporomandibular disorders? Clin Oral Invest 2006; 10: 261-8. 13. Okeson JP. Management of temporomandibular disorders and occlusion. 6th ed. 2008; pp. 468. 14. Okeson JP. Assessment of orofacial pain disorders. In Okeson J, editor: Orofacial pain: guideline for assessment, diagnosis, and treatment, Chicago, 1996, Quintessence, pp32-4. 15. Yusoff MSB, Yee LY, Wei LH, Meng LH, Bin LX, Siong TC, Abdul Rahim AF. A study on stress, stressors and coping strategies among Malaysian medical students. Int J Students' Res 2011; 1(2): 4550. 16. Yusoff MSB. Stress, Stressors & Coping Strategies among Secondary School Students in a Malaysian

Government Secondary School: Initial Findings. ASEAN J Psychiatry 2010; 11(2). 17. Khalid SAG. Depression, anxiety and stress among Saudi adolescent school boys. JR Prom Health 2007; 127(1): 33-7. 18. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med 2006; 81:35473. 19. Farsi NM: Symptoms and signs of temporomandibular disorders and oral parafunctions among Saudi children. J Oral Rehabil 2003, 30:1200-8. 20. Feteih RM. Signs and symptoms of temporomandibular disorders and oral parafunctions in urban Saudi arabian adolescents: a research report. Head and face medicine 2006; 5:567-71. 21. Thilander B, Rubio G, Pena L, Mayorga C Prevalence of temporomandibular dysfunction and its association with malocclusion in children and adolescents: an epidemiologic study related to specified stages of dental development. Angle Orthod 2002; 72:146-54. 22. Farsi N. Temporomandibular dysfunction and emotional status of 614 years old Saudi female children. Saudi Den J 1999; 11:114-9. 23. Deng Y, Fu MK, Hagg U. Prevalence of temporomandibular joint dysfunction (TMJD) in Chinese children and adolescents. A cross-sectional epidemiological study. Eur J Orthod 1995; 17:305-9. 24. Gesch D, Bernhardt O, Alte D, Schwahn C, Kocher T, John U, Hensel E. Prevalence of signs and symptoms of temporomandibular disorders in an urban and rural German population: Results of a population-based Study of Health in Pomerania. Quintessence Int 2004; 35:143-50. 25. Neill Mc C. Management of temporomandibular disorders: concepts and controversies. J Prosthet Dent 1997; 77:510-22. 26. Glaros AG. Temporomandibular disordes and facial pain: a psychophysiological perceptive. Appl psychophysiol Biofeedback 2008; 33: 161-71. 27. Fricton J. Myogenous temporomandibulae disorded: diagnostic and management consideration. Dent Clin North Am 2007; 51:61-83. 28. Dao TT, LeResche L. Gender differences in pain. J Orofac Pain 2000; 14:169-84. 29. Farsi NM: Symptoms and signs of temporomandibular disorders and oral parafunctions among Saudi children. J Oral Rehabil 2003; 30:1200-8. 30. Kuttila M, Niemi PM, Kuttila S, Alanen P, Le Bell Y .TMD treatment need in relation to age, gender, stress, and diagnostic subgroup. J Orofac Pain 1998; 12:67 74 31. Lobbezoo MD, Shafer D, Napolitano C. Momentary mood and coping processes in TMD pain. Health Psychology 2004; 23: 354 62. 32. Boever De JA, Carlsson GE, Klineberg IJ. Need for occlusal therapy and prosthodontic treatment in the management of temporomandibular disorders: Part I, Occlusal interferences and occlusal adjustment. J Oral Rehabil 2000; 27:367-79. 33. Pullinger AG, Seligman DA. Quantification and validation of predictive values of occlusal variables in temporomandibular disorders using a multifactorial analysis. J Prosthet Dent 2000; 83:66-75. 34. Gesch D, Bernhardt O, Alte D, Schwahn C, Kocher T, John U, Hensel E. Prevalence of signs and symptoms

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of temporomandibular disorders in an urban and rural German population: Results of a population-based Study of Health in Pomerania. Quintessence Int 2004; 35:143-50.

35. Fricton JR. Masticatory myofascial pain: an explanatory model integrating clinical, epidemiological and basic science research. Bull Group Int Rech Sci Stomatol Odontol 1999; 41:1425.

Table 1: The differences between classes in the percentage of stressful students by self report stress
Sex Male Female Total P value Total L68 192 360 5th secondary No.with stress % withy stress total 21 12.5 154 117 60.9 250 138 38.3 404 0.0001* 6th secondary No.with stress % withy stress 62 40.3 214 85.6 276 68.3

*Significant using Z-test at 0.05 level of significance

Table 2: The differences between classes in percentage of students had TMDs according to clinical examination
Sex Male Female Total P value total 168 192 360 5th secondary No. with % with TMD by clinical TMD examination 10 5.9 45 23.4 55 15.2 Total 154 250 404 6th secondary No. with % with TMD by clinical TMD examination 12 7.7 51 20.4 63 15.5

0.336
*Significant using Z-test at 0.05 level of significance

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Histological evaluation

Histological evaluation of osseointegration around titanium implants in thyroidectomized rabbits (experimental study).
Zaid M. Ali, B.D.S., M.Sc. (1) Nada M. H. Al-Ghaban, B.D.S., MSc., Ph.D. (2)

ABSTRACT
Background: Thyroid hormones are essential for linear growth and peak bone mass acquisition. Hypothyroidism occurs when the thyroid gland produces less than the normal amount of thyroid hormones. The present study was carried out to evaluate the effect of hypothyroidism on osseointegration around the titanium implants screwed in rabbit's tibia. Materials and methods :Fifty four machined surface Iraqi implants were inserted in 27 male rabbits (2implants in each rabbit's tibia ).Eighteen of these rabbits were subjected to near total thyroidectomy to induce hypothyroidism three weeks before implantation surgery. While the remaining 9 rabbits were remain as a control group. Blood sample was taken from each animal at the beginning of this study in order to find the normal range of T3,T4,and TSH .And another blood sample was taken for experimental groups to find the levels of T3,T4,and TSH three weeks after thyroidectomy in order to assess the hypothyroidism status .After 2, 4, 6 weeks after implant surgery (6rabbits from experimental group and 3rabbits from the control group) were sacrificed. In the day of scarification, one of the screws was unscrewed with a torque meter, and the peak torque required to shear off the implant was recorded. Then the decalcified sections of the bone around the implants were studied histologically and histomorphometrically .The eye piece reticule was used for morphometrical studies, which were includes: number of osteocytes, number of osteoblasts, thickness and number of bone trabeculae, and thread width Results:The results showed that hypothyroid rabbits had delay in osseointegration, bone formation and maturation around implants in almost all rabbits in experimental groups. While the rabbits in the control groups showed improvement in osseointegration around titanium implant. Removal torque test illustrated higher torque test value in control animals than in experimental one. Moreover, there were increases in torque test values in both groups with time. Biochemical serum analysis revealed a decrease in T3, T4, and increase TSH levels in experimental animals. Conclusion: It can be concluded that there were low bone quality with a delay in bone healing around titanium implants in hypothyroidied rabbits compared with healthy one. Key words: Hypothyroidism, Titanium implants, Rabbits tibia, Osseointegration. (J Bagh Coll Dentistry 2012;24(2):7579).

INTRODUCTION
Dental implant treatment has revolutionized oral rehabilitation in partially and fully edentulous patients. When the concept of osseointegration was introduced in relation to titanium endosseous implants (1).It became possible to achieve high success rates in association with this treatment modality, and multiple investigations have demonstrated an excellent long-term prognosis. The achievement and maintenance of osseointegration are highly dependent on bone quality and quantity. The systemic conditions may be correlated with impaired bone healing around titanium implants, especially in metabolic bone diseases such as osteoporosis, diabetes mellitus, and hypothyroidism (2). Bone is a highly metabolically active tissue in which the processes of osteoblastic bone formation (anabolic activity) and osteoclastic resorption (catabolic activity) are continuous throughout life.
(1) M.Sc.student, Department of Oral Histology and Biology, College of Dentistry, University of Baghdad (2) Ass.Professor, Department of Oral Histology and Biology, College of Dentistry, University of Baghdad

Therefore, the capacity of bone tissue to respond to injuries such as fracture or implant placement is associated with several mechanisms and may be affected by different conditions (3). Thyroid hormones are the major regulators of bone metabolism and development. Hypothyroidism is a condition in which the thyroid gland does not make enough thyroid hormone (A deficiency of thyroid hormone) to meet the bodys needs. Without enough thyroid hormone, many of the bodys functions slow down. The scientific consensus is that untreated hypothyroidism causes an abnormally decreased bone density coupled with poor bone quality, and have been linked to altered osteoblast and osteoclast activity, leading to an imbalance in bone turnover (4). Although thyroid dysfunctions may affect bone metabolism via their effect on thyroid hormone levels that influence bone turnover (5) there is a lack of information regarding the effect of changes in T3 and T4 serum levels on bone healing around titanium implants. Thus, the objective of this study was to clarify the establishment and maintenance of
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osseointegration in thyroidectomy hypothyroidism in rabbits tibia.

induced

MATERIALS AND METHODS


Twenty seven male adult New Zealand white rabbits aged from 9 to 12 months were used as animal model in this study. Their weights ranged between 1.5 to 2.5 kg .The animals were kept under the supervision from staff of the animals house of the College of Veterinary medicine. The animals of this study were divided into two groups, experimental group (18 rabbits) and control group (9 rabbits) .The animals of experimental group were subjected to near total thyroidectomy to induce hypothyroidism, three weeks before implant operation. The levels of thyroid hormones (T3, T4, and TSH) were detected before and three weeks after the thyroidectomy operation (6). After 2, 4, 6 weeks intervals, the most distal screw was exposed and unscrewed with a torque meter, and the peak torque required to shear off the implant was recorded. Then the decalcified sections of the boneimplants block were stained with (H&E) and VanGieson's stains for histological and histomorphometrical studies, which were includes: number of osteocytes, number of osteoblasts, thickness and number of bone trabeculae, and thread width The statistical analyses were calculated by SPSS (personal computer) (7). In all multiple comparisons significant p-value was at (p< 0.05).

Histomorphometrical analysis Trabicular thickness and number The results showed that there were significant(P0.01) decrease in the trabecular bone thickness in experimental group compared to their control in the 6th weeks interval only (Table. 2).While there were no significant differences in the trabecular number between the experimental and control groups in all healing periods (Table .3).

Table 2: Trabecular bone thickness (m)


group control H.P 2weeks 4weeks 6weeks 4.750.76 10.311.29 14.061.07 experimental 3.750.72 9.160.42 9.3750.81 P- value N.S N.S p0.01*

Table 3: Trabecular number in different groups


group control H.P 2weeks 4weeks 6weeks 2.750.5 5.330.76 3.400.79 experimental 2.600.05 4.830.61 3.00.91 P- value N.S N.S N.S

RESULTS
Torque removal test The lowest mean torque values for both groups were recorded in 2 weeks while the highest mean value was detected in 6 weeks. Also there was a significant (P0.01) decrease in the torque values of the experimental groups compared with their controls for healing period (Table. 1).

Number of osteocytes The results denote that there was a highly significant(P0.01)decrease in the number of osteocyts in 2 weeks of the experimental group but there was a significant(P0.05) increase in the number of osteocyte in the period of six weeks in the experimental group compared with the control group (Table .4) .

Table 4: Osteocytes number in different groups


group control H.P 2weeks 4weeks 6weeks 27.331.76 31.673.3 21.670.9 experimental 16.332.60 28.602.1 26.752.21 P- value P0.01** N.S P0.05*

Table 1: Torque test values of different groups


group control H.P 2weeks 4weeks 6weeks 9.830.50 18.831.17 23.440.78 experimental 4.771.16 10.00.38 14.01.4 P- value P0.01* P0.01* P0.01*

Number of osteoblast: The results showed that there is there was a highly significant decrease (P0.01) in the number of osteoblasts in the experimental groups as compared with their controls in all healing periods (Table. 5).

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Table 5: Number of osteoblast in study groups


group control H.P 2weeks 4weeks 6weeks 29.51.56 25.661.04 20.331.26 experiment al 26.330.72 22.661.53 16.331.53 P- value P0.01* P0.01* P0.01*

Thread width The results indicate that there was a significant reduction in thread width of experimental animals of 4 and 6 weeks healing periods when compared with their controls (Table .6 ) .

Figure 2: Experimental group at 2weeks duration showing newly formed bone trabecule(B.T) (Van-gieson's stain X 200).

Table 6: Thread width in study groups (m).


group control H.P 2weeks 4weeks 6weeks 18.1252.13 21.8751.88 26.51.27 experimental 17.51.44 18.757.2 20.6250.63 P- value N.S P0.05* P0.01**

Histological findings: The histological findings in 2-weeks interval showed large and numerous bone trabeculae in control group, while there was few and small bone trabeculae in the thread of experimental group (Figures 1,2). The histological appearance of 4-weeks interval revealed immature bone which almost fill the whole thread in control group (Figure.3), while in the experimental group of the same period showed that there was fibrous connective tissue in near the implant surface with immature bone (Figure.4,5). The histological picture of 6-weeks interval of the control group illustrated mature bone with numerous incremental lines that fill the whole thread of cortical bone region(Figure 6), and thick bone trabeculae near the implant surface in the bone marrow region (Figure 7). While the picture of experimental group of the same period revealed still immature bone that fill the whole thread in the compact bone region (Figure 8).

Figure 3: Control group at 4weeks duration showing osteoblast (OB), osteocytes(OS).(H&E X200)

Figure 4: Experimental group in 4weeks duration Showing preosteocytes (POS),osteoclast(OC) (H&E X200).

Figure 5: Experimental group at 4weeks duration showing immature compact bone with large size osteocytes (OS), preosteocytes(POS) (Van-gieson's stain X400). Figure 1: Control group at 2weeks duration showing osteocytes(OS) inside bone trabecule (Van-gieson's stain X200).
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Figure 6: Control group at 6weeks duration .Revealing mature bone thread with numerous incremental lines (arrows) (H&E X400).

Histomorphometrical analysis: T3 regulates the differentiation of osteoblasts, by increasing the expression of many genes of the osteoblastic phenotype like osteocalcin, osteoprotegerin ,and this may explain the decreased number of osteoblasts in the experimental groups in all the study periods compared with their controls (10). Because of ostecytes are derived from osteoblasts(11) , the effect of thyroid hormones reduction on osteoblasts can be seen in osteocyte numbers in the experimental groups. Also this study showed decrease in trabecular thickness and numbers in the hypothyroid animals than controls .This most probably due to low bone turnover in hypothyroisim which affect both bone resorption and bone formation and cause reduction in osteiod apposition (12). Hypothyroidism resulted in less newly formed bone within the implant threads and this may explain the reduction in thread width of new bone formed around the implant screwed in the experimental animals. This finding agree with Wilkins et al(13). Histological and histochemical findings: The histological finding of control rabbits of 2weeks interval showed newly formed woven bone with new bone trabeculae .While the hypothyroid rabbits showed generalized delay in bone remodeling in comparison with control rabbits. This finding may be due to the fewer number of active osteoblasts in the hypothyroid rabbits which are responsible for the formation of new bone matrix. This finding agrees with Williams (14) The histological picture of control animals at 4weeks duration manifested dense newly formed bone rather than trabecular appearances, and osteocytes were trying to get concentric arrangement around haversian canal. While in experimental group the newly formed bone had a trabecular appearance. Osteocytes still irregularly arranged. Osteoclasts and reversal lines were widely seen in the newly formed bone which may gave the indication of continuous bone remodeling. These differences might be attributed to the decrease in the secretion of T3 and T4 in hypothyroid animals which cause delay in bone formation and maturation .This result correlate with previous study done by Williams (15). The histological and histochemical findings of the control animals at 6weeks duration showed almost mature newly formed bone threads .It had the same mature appearance of the original bone .while in experimental animals of this period, the newly formed bone in general was not completely
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Figure 7: Microphotograph of the control group at 6weeks duration revealing bone trabecule in bone marrow region Outline the thread (Van-gieson's stain X200).

Figure 8: Experimental group at 6 weeks showing immature bone with large size osteocytes (arrows) (H&E X200).

DISCUSSION
This study showed increase in removal torque value over time for both experimental and control groups. It has been suggested that this increase depends on increasing bone-to-implant contact with time as a result of progressive bone formation and maturation around implant during healing, which substantially improved the mechanical capacity (8).On the other hand, the increased removal torque values for control animals comparing with hypothyroid animals in all healing periods indicated that hypothyroidism may affect the bone formation and maturation around the implants negatively (9).
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mature and the osteocytes still irregularly arranged. These slight differences in bone healing between experimental and control in histological and histochemical findings may be due to the effect of hypothyroidism on bone healing around titanium implants (13,15). It was also shown that an imbalance in the levels of T3 and T4 correlated positively with the levels of the factors involved with bone homeostasis. For instance, a decrease in osteoprogenitor cells, growth factors, and cytokines, resulting in a decreased bone apposition, was reported for hypothyroidism (16). The present study was done to evaluate the effect of thyroid hormones on bone healing around titanium implants in thyroidectomized rabbits. The findings presented here clearly demonstrate that clinicians should not underestimate these conditions when dealing with patients diagnosed with hypothyroidism that are referred for implant placement.

11. Salman S, Aral F, Boztepe H, Colak N, Omer B, Tanakol R, Alagol F& Uzum K. Evaluation of the association between bone turnover markers and OPG/sRANK-L levels in relation with the changes of thyroid function in women with thyroid cancer. European Congress of Endocrinology .Endocrine Abstracts 2009; 20:P238. 12. Feitosa DS, Bezerra BD, Ambrosano GM, Nociti Jr FH, Casati MZ , Sallum EA,Toledo SD. Thyroid Hormones May Influence Cortical Bone Healing Around Titanium Implants. J Periodontal Res 2008 ; 79:7:881-887. 13. Wilkins SB, Clark DM, Bain BJ, Bone Marrow Pathology. DESEASES OF BONE 2011; P: 469. 14. Williams GR, The bare bones of thyroid hormones. Endocrine Abstracts 2011; 25: 6. 15. Williams G R, Actions of thyroid hormones in bone. Polish J Endocrinology 2009;(60)5:380-388. 16. Bonewald LF. Osteocytes In Osteoporosis,3ed. Marcus R, Feldman D, Nelson DA, Rosen CJ, eds. Burlington. Elsevier Academic Press 2007; 169190.

REFERENCES
1. Quilligan G, Osseointegration and dental implants. British Dent J 2010; 208: 41 - 42. 2. Kopman JA, Kim DM, Rahman SS, Arandia JA, Karimbux NY, Fiorellini JP.Modulating the effects of diabetes on osseointegration with aminoguanidine anddoxycycline . J Periodontol 2005; 76: 614-620. 3. Ennis BJ. Agglomeration technology mechanism. Chem. Eng 2010; 117 (3) 34. 4. Little JW.Thyroid disorders. Part I: Hyperthyroidism. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006a; 101:276-284. 5. Talaeipour AR, Shirazi M, Kheirandish Y, Delrobaie A, Jafari F, Dehpour AR. Densitometric evaluation of skull and jaw bones after administration of thyroid hormones in rats. Dentomaxillofac Radiol 2005; 34:332-336. 6. Edmonds C J, Hayes S , Kermode M , Thompson BD. Measurement of serum TSH and thyroid hormones in the management of treatment of thyroid carcinoma with radioiodine. British J of Radiology 1977; 50: 799-807. 7. SPSS: Statistical package of social science; version16 and17(Win/Mac/Linux,user'sguidespssinc.,Chicago, USA,website,http://www.spss.com/. 8. Conti MI, Martnez MP, Olivera MI, Bozzini C, Mandalunis P,Bozzini CM, Alippi RM. Biomechanical performance of diaphyseal shafts and bone tissue of femurs from hypothyroid rats Endocrine 2009; ( 36),r2: 291-298. 9. Varga F, Rumplera M, Zoehrerb R, Tureceka C, Spitzera S, Thalera R, Paschalisa EP, Klaushofera K.. T3 affects expression of collagen I and collagen cross-linking in bone cell cultures. Biochem Biophys Res Commun. 2010 ;(12):402(2-3): 180185. 10. Freitas FR, Capelo LP, OShea PJ, Jorgetti V, Moriscot AS, Scanlan TS, Williams GR, Zorn TM & Gouveia CH . The thyroid hormone receptor betaspecific agonist GC-1 selectively affects the bone development of hypothyroid rats. J Bone and Mineral Research 2005; 20: 294304.

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Prevalence of pulp stone

Prevalence of pulp stone (Orthopantomographic-based)


Zainab H. Al-Ghurabi, B.D.S., M.Sc. (1) Areej A. Najm, B.D.S., M.Sc. (2)

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

INTRODUCTION
Pulp stones are calcified bodies in the dental pulps of the teeth in the primary and permanent dentition. They can be seen in the pulps of healthy, diseased, and even unrequited teeth (1). Their locations are more common in the coronal than in the ridiculer portions of the pulp and they can be observed as free, attached, and embedded in the dentinal surface of the Pulp chamber. Pulp stones are classified according to their structure as true, false, and diffuse. They range in size from small microscopic particles to large masses that almost obliterate the pulp chamber (2). Although the exact cause of pulp calcification is unknown some factors have been implicated in stone formation such as genetic predisposition (3), orthodontictooth movement, dentine dysplasia, dentinogenesis imperfect and in certain syndromes such as Vandrwoude syndrome (4) circulatory disturbance in pulp, age (5), interactions between the epithelium and pulp tissue, idiopathic factors (6), and long-standing irritants like caries, deep restorations, and chronic inflammation (7).
(1)Assistant lecturer, Department of Oral and Maxillofacial Surgery. College of Dentistry, University of Baghdad (2) Assistant lecturer, Department of Oral and Maxillofacial Radiology. College of Dentistry, University of Baghdad

Studies related to the prevalence of pulp stones, based on radiographic examinations, have been reported with various percentages (ranging from 8% to 95%) (1, 8, 9). With age the pulp spaces of teeth decrease in size through the deposition of secondary and tertiary dentine. When tooth wear, caries or operative intervention is a feature this process becomes more evident. In most pulps, dystrophic calcification is found to be of a variable degree, and even in teeth without caries or restorations scattered calcification occurs, unrelated to disease (10) . Pulp stones can be structurally classified and based on location (10,11). Structurally, there are true and false pulp stones; the distinction being morphological. A third type, diffuse or amorphous pulp stones, is more irregular in shape than false pulp stones, occurring in close association with blood vessels (10, 12). True pulp stones are made of dentine and lined by odontoblasts, whereas false pulp stones are formed from degenerating cells of the pulp that mineralize (4). Such mineralization occurs in stages; initially cell nests become enclosed by concentrically arranged fibers (i.e. an organic phase precedes mineralization) which then become impregnated with mineral salts. Calcified increments are then added (1,2). Based on location, pulp stones can be embedded, adherent and free. Embedded stones are formed in the pulp but with
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ongoing physiological dentine formation they become enclosed (sometimes fully) within the canal walls (10, 13). They are found most frequently in the apical portion of the root and the presence of odontoblasts and calcified tissue resembling dentine can occur on the peripheral aspect of these stones (2). Adherent pulp stones are simply less attached to dentine than embedded pulp stones; the difference between adherent and embedded can be subjective, but adherent stones are never fully enclosed by dentine. Adherent and embedded pulp stones can interfere with root canal treatment if they cause significant occlusion of canals or are located at a curve (10). They may also become dislodged. Free pulp stones are present within the pulp tissue proper and most commonly seen type on radiographs (10.14). The aim of this radiographic-based study was to determine the prevalence of pulp stones, and to evaluate possible associations between pulp stones and gender, tooth type, and side, and to compare the results with published data presenting a new perspective in forensic medicine.

ensure of the accuracy of the diagnosis, only the teeth that were confirmed by our two examiners to have pulp stones were scored as present.

RESULTS
A total of 390 patients (221 females and 169 males) participated in the present study. The age range of the subjects was 15 - 50 years, pulp stone were observed in 136 patients with 276 teeth; 75 female with 143 teeth and 61male with 133 teeth, as shown in table 1. According to the gender the occurrence of pulp stone in female was slightly higher than in male, so the pulp stone in female upper 1st molar was found in 40 teeth (14.9%),while in male 35 teeth (12.7%). In female the upper 2nd molar was found in 37 teeth (13.4%), while in male was 25 teeth (9%). The pulp stone in female upper 1st premolar was found in 3 teeth (1.2%), in male was found in 2 teeth (1.3%), in 2nd upper premolar for female was found in 1 tooth (0.3%), while for male was found in 2 teeth (0.7%). For mandible the 1st molar in female was found in 78 teeth( 28.2%), while in male was found in 43 teeth (15.5%), lower 1st premolar in female was found in 2 teeth (1.3%), in male was found in 3 teeth (1.2%), for lower 2nd premolar in female was found in 3 teeth (1.2%), while in male was found in 1 tooth (0.3%).Total number of teeth with pulp stone in female was 143 teeth (51.8) and in male was found in 133 teeth (48.1), as shown in table 1. According the arch also the difference between upper and lower arch was very small so the total number of 1st molar in maxilla was75 teeth (27.1%), while in mandible was 78 teeth (28.2%), and 2ns molar in maxilla was 62 teeth (22.4%), while in mandible was 43 teeth (15.5%). The total number of 1st premolar in maxilla was 7 teeth (2.6%), while in mandible was 5 teeth (1.5%), and 2nd premolar in maxilla was 3 teeth (1%), while in mandible was 4 teeth (1.4%), the total number in the maxilla was 146 teeth (52.8), while in the mandible was 130 teeth (47.1) so the difference between maxilla and mandible was no significant, as shown in table 1. P=< 0.2 According tooth type the statistic study show that, Pulp stones were found in only 18 (6.8 %) of the premolars and in 258 (93.2 %) of the molars examined, with differences in occurrence being statistically significant (p<0.01).The frequency of pulp stones was higher in the first molars than in the second Molars and in first premolars than in second premolars in each dental arch.

SUBJECTS AND METHODS


A total of 390 digital panoramic radiographs (OPG) were collected from oral diagnosis department /College of Dentistry, University of Baghdad and Al-Karkh General Hospital. Digital panoramic radiographs were taken by using DIMAX3 digital x-ray unit system machine (Finland). The sample composed of 169 male and 221 female with mean age (26.9 years). Information about name, age and gender had been recorded for each patient. The digital panoramic radiographs were examined by two oral and maxillofacial radiologists at the same time after put the radiograph on a viewer; Only Images of good quality which had the clearest reproduction of teeth without any superimposition were included. About 10510 teeth were evaluated; teeth with crowns or bridges that prevented adequate vision of the pulp chamber were not included in the study sample. Considering that teeth with deep fillings and caries lesions are more inclined to have pulp stones, only teeth which were noncarious and undestroyed, or those with shallow fillings, were included. Definite radiopaque bodies observed inside the pulp chambers of the teeth were identified as pulp stones (Fig. 1,2) and were scored as present or absent, number of stone and associations with, gender, dental arch and tooth type were recorded. No attempt was made to determine the details of the pulp stones, such as their size, type and location in the pulp chamber and the condition of the associated tooth. To
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DISCUSSION
Calcification in the dental pulp can lead to denticles, commonly known as pulp stones. They are hard, bone-like structures that form within the pulp of tooth, either within the crown or within the root canals. They are usually detected on Xray examination, present as a radiopaque entity in either the pulp chamber and/or root canal space. They may be either singular or multiple and can be detected easily unless they are too small or not dense enough to show up on an x-ray. Pulp stones are incidental findings and do not need treatment and in the literature the incidence of pulp stones has been investigated in many histological and radiological studies based on periapical or bitewing radiographs but there is no study evaluate the prevalence of pulp stone using the digital panoramic radiograph (OPG). When the literature related to pulp stones was reviewed, there were a limited number of studies regarding the incidence of pulp stones. Moreover, the reported rates of prevalence also differed in the studies. Some researchers reported prevalence based on the number of patients and teeth (1), whereas the others represented only the rates based on teeth numbers (8,9,15,16). In the present study, we presented rates based both on the number of patients and teeth. On the basis of the number of patients we found the rate of prevalence to be 34.8%, which is within the reported range in the literature (1, 9, 17, 18, 19). On the basis of numbers of teeth examined, we found 276 teeth with pulp stones and the percentage is 7.3 %, and this is within the range reported by other researchers in previous studies, Baghdady et al. in 1988 found (14.8%) out of the 6,228 teeth examined in a teenage group of 515 subjects. In another study conducted by Al-Hadi and Darwazeh in 1998, the prevalence of pulp stones was found to be 22.4 % in 1,028 of 4,573 teeth examined. Ranjitker et al. found the prevalence to be 10.1 % in 333 out the 3,296 teeth examined (17). Another report related to the prevalence of pulp stones showed pulp stone incidence to be 4.8 % in 747 out of the 15,326 teeth examined (9). In the present study, we found that the prevalence of pulp stones was 15 % in 1,038 of 6,926 teeth examined. Sisman et al. reported 15 % as pulp stone prevalence in molars and premolars teeth of Turkish population. According to gender, from 136 patients with pulp stones, 75 were females (with 143 teeth have pulp stones) and 61 were males (with 133 teeth have pulp stones), so the female was more than males but there are no significant differences between the genders in each tooth type and arch. The
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prevalence of pulp stones noted in females and males in this study agrees with previous studies that it is greater in female (1,7,8,16,18). In the present study, the occurrence of pulp stones was more frequently found in the maxilla than in the mandible in each tooth type and location (right- left). In the maxillary arch there are (146) teeth with pulp stones while in mandibular arch there are (130) teeth, so the occurrence is higher in maxilla but the difference is not significant statically. These results are in agreement with previous studies (1, 17). In the present study pulp stones were significantly more common in first molars than in second molars, premolars and incisors in both maxillary and mandibular arches. Also the first premolar is more than second premolar in both arches. This results are in agreement with other studies (1,16-18). A probable explanation of this result may be related to the fact that the molars are the largest teeth in the arch, provide a better supply of blood to the pulp tissue and have the strongest chewing force in the arch. This may lead to greater precipitation for calcification (1). Also the early eruption of the first molar will expose them for long period of time to more degenerative changes, thus confirming that calcification of the pulp increases with age.

REFERENCES
1. Sisman Y, Aktan A M, Tarm-Ertas E, ifti M E, ekerci AE . The prevalence of pulp stones in a Turkish population. A radiographic survey. Med Oral Patol Oral Cir Bucal 2011. 2. Johnson PL, Bevelander G. Histogenesis and histochemistry of pulpal calcification. J Dent Res 1956; 35:714-22. 3. VanDenBerghe JM, Panther B, Gound TG. Pulp stones throughout the dentition of monozygotic twins: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 87:749-51. 4. kumar K. Bahetwar A., Pandey K. An unusual case report of generalized pulp stones in young permanent dentition. Contemp Clin Dent 2010; 1(4): 281283. 5. Hillmann G, Geurtsen W. Light-microscopical investigation of the distribution of extracellular matrix molecules and calcifications in human dental pulps of various ages. Cell Tissue Res 1997; 289:145- 54. 6. Siskos GJ, Georgopoulou M. Unusual case of general pulp calcification (pulp stones) in a young Greek girl. Endod Dent Traumatol 1990; 6: 282-4. 7. Sundell JR, Stanley HR, White CL. The relationship of coronal pulp stone formation to experimental operative procedures. Oral Surg Oral Med Oral Pathol 1968;25: 579-89. 8. Baghdady VS, Ghose LJ, Nahoom HY. Prevalence of pulp stones in a teenage Iraqi group. J Endod 1988; 14:309-11.

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9. Sener S, Cobankara FK, Akgunlu F. Calcifications of the pulp chamber: prevalence and implicated factors. Clin Oral Investig 2009; 13:209-15. 10. Goga R, Chandler N, Oginni A. Pulp stones: a review. International Endodontic J 2008; 41: 45768. 11. Seltzer S, Bender IB. The Dental Pulp, 3rd ed. Philadelphia, PA: J.B. Lippincott Company 1984. 12. Mjor IA, Pindborg JJ. Histology of the human tooth. Copenhagen: Munksgaard, 1973. pp. 612. 13. Philippas GG. Influence of occlusal wear and age on formation of dentin and size of pulp chamber. J Dent Res 1961; 40: 118698. 14. Sayegh FS, Reed AJ. Calcification in the dental pulp. Oral Surgery, Oral Medicine, Oral Pathology 1968; 25: 87382.

15. Tamse A, Kaffe I, Littner MM, Shani R. Statistical evaluation of radiologic survey of pulp stones. J Endod 1982; 8:455-8. 16. Al-Nazhan S., Al-Shammrani S. Prevalence of Pulp Stones in Saudi Adults. ADJ 1991: 129-142. 17. Ranjitkar S, Taylor JA, Townsend GC. A radiographic assessment of the prevalence of pulp stones in Australians. Aust Dent J 2002; 47:36-40. 18. Gulsahi A., Cebeci A., zden S. A radiographic assessment of the prevalence of pulp stones in a group of Turkish dental patients. International Endodontic J 2009; 42(8): 7359. 19. Al-Hadi Hamasha A, Darwazeh A. Prevalence of pulp stones in Jordanian adults. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 86:730-2.

Table 1: Distribution of pulp stone according to arch for both genders


`1st molar 2nd molar Maxilla `1st premolar 2nd premolar total `1st molar 2nd molar Mandible `1st premolar 2nd premolar total Total No. 35 25 4 2 66 38 25 3 1 67 133 Male % 12.68% 9.% 1.4% 0.7% 23.9% 13.76% 9% 1.2% 0.35% 24.2% 48.1%
P< 0.2

Female No. % 40 14.49% 37 13.4% 3 1.2% 1 0.3% 81 29.1% 40 14.49% 18 12.5% 3 1.2% 1 0.35% 62 22.8% 142 51.8

Total% 75 (27.1%) 62 (22.4%) 7 (2.6%) 3 (1%) 146 (53.%) 78 (28.2%) 43 (15.5%) 6 (2.4%) 2 (0.7%) 130 (47.1) 100%

Figure 1: Digital Panoramic Radiograph showing pulp stone.

Figure 2: A: pulp stones in the pulp chamber of maxillary and mandibular second molars. B: pulp stones in the pulp chamber of maxillary first and second molars. 35% (276 teeth of 136 subjects) with pulp stone
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Figure 3: This figure show the percentage of teeth involved with pulp stone.
5% 1s t premolar

55% 1st molar (Red) 38% 2nd molar (Green) 5% 1st premolar (Blue) 2% 2nd premolar (violet) No significant difference between maxilla and mandible Figure 4: Pulp stone distribution according to tooth type for both arcs

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Evaluation of the haemostatic

Evaluation of the haemostatic action of povidone- iodine in dental extraction (Clinical and follow up prospective study)
Ali Q.L. Al-Amiri, B.D.S, M.Sc. (1)

ABSTRACT
Background: This study aimed to evaluate the haemostatic action of povidone-iodine by irrigation of the alveolar sockets after extraction against the use of normal saline alone. Materials and Methods: This clinical prospective study included 60 patients (35 males, 25 females), ranging in age from 20 to 60 years. All minor oral surgery patients at (Oral& Maxillofacial Surgery Department in College of Dentistry/ Babylon University) from March 2011 to January 2012. The patients were divided equally into treatment& control groups. Povidone-iodine (1%, w/v) was used for irrigation of extraction sockets in the treatment group and saline was used in the control group. Results: The 60 patients were divided equally into treatment& control groups. Povidone-iodine (1%, w/v) was used for irrigation of extraction sockets in the treatment group and saline was used in the control group. In the treatment group, 24 patients showed cessation of bleeding compared to only 7 in the control group. Povidone-iodine significantly (P < 0.01) controlled bleeding as compared to saline. Conclusion: Iodine is corrosive due to its oxidizing potential while povidone is a thickening and granulating agent; together they have a chemocauterizing effect that could be the reason for the cessation of bleeding. Keywords: Povidone iodine, Haemostatic action. (J Bagh Coll Dentistry 2012;24(2):85-87).

INTRODUCTION
The use of topical antimicrobial agents is common in clean and contaminated surgical wounds, based on the premise that reduction of superficial bacterial contamination aids wound healing. Povidone iodine is a widely used and highly potent antiseptic. Iodine was first used medically to produce inflammation and obliteration of serous cavities. It is commonly used both on intact skin in preparation for surgery and on open wounds. Acute lacerations are soaked in iodine and surgical wounds are freely irrigated with it10. Povidone-iodine is formed by binding free iodine to polyvinyl-pyrrollidone (PVP), a solubilizing agent. This is done to decrease the toxicity of the iodine. As iodine is liberated from the PVP molecule it exerts its antimicrobial effect3. Once released, iodine is toxic to microorganisms because it combines irreversibly with tyrosine residues of proteins, interferes with the formation of hydrogen bonding by some amino acids and nucleic acids, oxidizes sulfydryl groups and reacts with sites of unsaturation in lipids4&7. Povidone iodine is a broad spectrum antimicrobial solution effective against a variety of pathogens including Staphylococcus aureus. However, similar wound infection rates have been reported in adult and pediatric populations with saline irrigation versus 1% povidone-iodine2&13.

(1)Assistant Lecturer, Department of Oral & Maxillofacial Surgery, College of Dentistry, Babylon University.

In addition to antibiotic prophylaxis, preparation of the surgical field with povidone iodine has been widely recommended12. Iodine is corrosive due to its oxidizing potential while povidone is a thickening and granulating agent; together they may have a chemocauterizing effect that could be the reason for the cessation of bleeding6. In oral surgery, Povidone-iodine is used as an irrigant of the alveolar sockets following dental extractions as antiseptic& haemostic. Extraction of diseased and malformed teeth is an essential part of oral surgery. Indications for extraction include: end-stage periodontal disease, end-stage endodontic disease, pulp exposure when endodontic treatment is not elected, malocclusions, crowding, retained deciduous teeth, trauma, and so forth. The present authors observed by chance that there was a cessation of fresh bleeding in some patients after irrigation with Povidone-iodine5. For medical uses, saline is often used to flush wounds and skin abrasions. Normal saline will not burn or sting when applied8. Normal saline is isotonic and the most commonly used wound irrigation solution due to safety (lowest toxicity) and physiologic factors. A disadvantage is that it does not cleanse dirty, necrotic wounds as effectively as other solutions 2&13 . This study aimed to evaluate the haemostatic action of povidone-iodine by irrigation of the alveolar sockets after extraction against the use of normal saline alone.

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MATERIALS AND METHODS


This clinical study was carried out on (60) healthy Iraqi patients who needed dental extractions. These patients were (35 males, 25 females), ranging in age from 20 to 60 years (Table 1-1). All minor oral surgery patients with multiple extractions (multiple sockets) at (Oral& Maxillofacial Surgery Department in College of Dentistry/ Babylon University) from March 2011 to January 2012. The patients were divided equally into treatment& control groups. The alveolar sockets of the treatment-group patients were irrigated immediately after extraction 3 times by using disposable syringe of (5cc) with povidone iodine 1% (w/v) (Betadine, WinMedicare, Germany) plus saline (sodium chloride 0.9%, w/v; Parenteral Drugs, Germany) following dental extractions, whereas those of the controlgroup patients were irrigated with saline only. Spontaneous stoppage of bleeding from the socket following irrigation was considered as significant haemostasis. Haemostasis was examined visually. Care was taken not to compress the socket to reduce the linear micro-fractures until observations were made. All the patients were followed up after 24 hours, and blood clot inside the sockets was firm without complications. Inclusion and exclusion criteria for the patients are listed as follow: Inclusion Criteria: (Age between 20 and 60 years, No history of bleeding disorders, No history of complications of previous extractions). Exclusion criteria: (Patients on anti-coagulant therapy, History of hypersentivity to iodine, Long-term NSAID therapy, menstrual cycle& hormonal changes in females, Conditions, such as periodontitis, gingivitis and dental abscess).

postoperative complications were observed in the patients of either group.

DISCUSSION
The most common age group involved was 2130 years; they showed a good response of haemostasis with povidone iodine due to their good health status with simple extractions. This age group comes into agreement with the age group of 15-33 years in the study by1 We found in this study, the haemostasis response in males was higher than females, and this might be due to the exclusion criteria in the point which is related to females, and this comes into agreement with the study by9 . Povidone is a synthetic polymer of 1vinylpyrrollidone, which is hygroscopic and readily soluble in water. It is also a thickening and dispersing agent with tablet binding capacity (wide firm binding) (SEAN, 2002). Iodine has a corrosive effect on tissues due to its oxidizing potential11. It seems possible that the haemostatic action of povidone iodine is due to the corrosive property of iodine and the thickening and binding properties of povidone. Iodine may chemocauterize the tissues while povidone may aid in clotting6. We found in this study that 24 patients in the treatment group have a haemostasis with irrigation by povidone iodine due to the good health status and simple cases of extractions, while the other 6 patients have no response to haemostasis, and the cause might be due to the lower health status when compared with the previous 24 patients. This result comes into agreement with the result in the study by8. While the haemostatic effect of normal saline is less than that of povidone iodine, because normal saline do not have a chemo-cauterizing action on the tissues, but just flush the wounds and make isotonic action with the wounds. This comes into agreement with2&13 .

RESULTS
The (60) patients were divided into 2 groups (n = 30), the treatment and control groups; the control group had 12 women and 18 men, and the treatment group consisted of 16 women and 14 men (Table 2). In the treatment group, 24 of the 30 patients showed spontaneous cessation of fresh bleeding (Table 3) following irrigation of the extraction socket with povidone iodine (1% w/v), while this was observed in only 7 of the 30 patients irrigated with saline (Table 4). This observation was made before drying the socket with gauze following which the sockets were compressed. Postextraction bleeding was significantly controlled by povidone iodine as compared to saline. No
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REFERENCES
1. Alexander RE, Dental extraction wound management: a case against medicating postextraction sockets, J Oral Maxillofac Surg 2000; 58: 53851. 2. Chisholm CD, Cordell WH, Rogers K, Woods JR. Comparison of a new pressurized saline canister versus syringe irrigation for laceration cleansing in the emergency department. Ann Emerg Med 1992; 21(11):1364-7. 3. Dedo DD, Alonso WA, Ogura JH, Povidone-iodine an adjunct in the treatment of wound infections, dehiscences and fistulas in head and neck surgery, Trans Am Acad Opthalmol Otolaryngol 2005; 84: 68 74.

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4. Gottardi W. Iodine and iodine compounds. In: Block SS (ed). Disinfection, sterilization and preservation. Philadelphia: Lea & Febiger; 2003. p.18396. 5. Hellem S, Nordenram A. Prevention of postoperative symptoms by general antibiotic treatment and local bandage in removal of mandibular third molars, Int J Oral Surg 1973; 2: 273. 6. Kumar BPR, Maddi A, Ramesh KV, Baliga MJ, Rao SN, Meenakshi. Department of Oral and Maxillofacial Surgery, College of Dental Surgery, Mangalore, Karnataka, IndiaDepartment of Pharmacology, Kasturba Medical College, Mangalore, Karnataka, India Department of General Surgery, Kasturba Medical College, Mangalore, Karnataka, India, 2006. 7. Markham SM, Rock J. Preoperative care. In: Rock JA, Thompson JD (ed): Te Linde's Operative Gynaecology 8th ed. Philadelphia: Lippincott-Raven; 1997. p. 233 43. 8. Principi T, Komar L. A critical review of a randomized trial of nebulized 3% hypertonic saline

9.

10.

11.

12.

13.

with epinephrine in the treatment of acute bronchiolitis in the emergency department. J Popul Ther Clin Pharmacol 2011; 18(2): e2734. PMID 21633141 Sweetman SC (ed). Disinfectants and preservatives. In: Martindale the complete drug reference. 33rd ed. London 2002. p. 1155. Senn N. Iodine in surgery with special reference to its use as an antiseptic. Surg Gynecol Obstet 1905; 1: 1 10. Swaryard EA, Lowenthal N (eds). Pharmaceutical Necessities. In: Remington's Pharmaceutical Sciences. 18th ed. Philadelphia 1990. p. 1307. Sweet RL, Gibbs RS, Editors, Wound and episotomy infection. In: Infectious Diseases of the female Genital Tract 2nd ed. Baltimore: Williams and Wilkins; 2000. p. 37482. Watt BE, Proudfoot AT, Vale JA. Hydrogen peroxide poisoning. Toxicol Rev 2004; 23(1): 51-7.

Table 1: Demography or age range of the patients


Age range 20 21-30 31-40 41-50 51-60 Total Frequency 3 22 17 15 3 60 Percentage 5% 31.7% 33.3 25% 5% 100% Treatment group 2 17 5 4 2 30 Control group 1 5 12 11 1 30

Table 2: Gender or sex distribution of the patients (Control group& Treatment group)
Gender Male Female Total Number of cases (control group) 18 12 30 Percentage 60% 40% 100% Number of cases (treatment group) 14 16 30 Percentage 46.67% 53.33% 100%

Table 3: The haemostatic action of povidone iodine on the treatment group (significant)
Cessation of bleeding Yes No Total Number of cases 24 6 30 Percentage 80% 20% 100% Gender 13males+11females 1males+5females 30

Table 4: The haemostatic action of normal saline on the control group (non significant)
Cessation of bleeding Yes No Total Number of cases 7 23 30 Percentage 23.33% 76.67% 100% Gender 5males+2females 13males+10females 30

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A comparison between the antibacterial and antifungal effects of chlorhexidine digluconate (An in vitro study)
Firas H. Qanbar, B.D.S., M.Sc. (1)

ABSTRACT
Background: The use of antimicrobial agent to control plaque and oral disease has been advocated for a number of years. Different compounds have been delivered through mouth rinses or tooth pastes or by topical application. The purpose of this research is to find out and to compare between the antibacterial and antifungal properties of Chlorhexidine digluconate 0.2%. Materials and methods: Mutans streptococci & Candida albicans were isolated from 25 saliva samples from healthy volunteers (age range between 21-23 yrs). These isolates were purified and diagnosed according to morphological characteristics and biochemical tests. Chlorhexidine 2mg/ml (0.2%) was used in the in vitro; susceptibility of Mutans streptococci and Candida albicans were tested by agar diffusion technique. Results: Agar diffusion technique showed that Chlorhexidine (0.2%) inhibited the growth of Mutans Streptococci, and Candida albicans, but the effect of Chlorhexidine (0.2%) on Candida albicans was more patent than on Mutans Streptococci in vitro. There was statistically highly significant difference (p<0.001) between the antifungal and antibacterial effects of Chlorhexidine on the sensitivity of the isolates, Conclusion: Chlorhexidine digluconate 0.2% was more potent as an antifungal than an antibacterial agent. Key words: Chlorhexidine digluconate, mutans streptococci, Candida albicans. (J Bagh Coll Dentistry 2012;24(2):8890).

INTRODUCTION
The use of antimicrobial agent to control plaque and oral disease has been advocated for a number of years (1). Different compounds have been delivered through mouth rinses or tooth pastes or by topical application. Some chemical agents have proven to be helpful against plaque accumulation and thereby to some extent also against caries (2). Oral mutans streptococci (MS) are responsible for 5070% of all cases of bacterial endocarditis. The origins of endocarditis lie in invasion of the vascular system through lesions in the oral mucosa (3). These streptococci can attach to the proteins covering the tooth enamel, where they then convert sucrose into extra cellular polysaccharides (mutan, dextran, levan) (4). These sticky substances, in which the original bacterial layers along with secondary bacterial colonizers are embedded, form dental plaque. The final metabolites of the numerous plaque bacteria are organic acids that breach the enamel, allowing the different caries bacteria to begin destroying the dentin (5). A few fungi have developed a commensal relationship with humans and are part of the indigenous microbial flora (e.g., various species of Candida, especially Candida albicans) (6). The first exposure to fungi that most humans experience occurs during birth, when they encounter the yeast Candida albicans (C. albicans) while passing through the vaginal canal. C. albicans accidentally penetrate barriers such as

intact mucous membrane linings, or when immunologic defects or other debilitating conditions exist in the host, these conditions favorable for fungal infections (7).

MATERIALS AND METHODS


Stimulated saliva samples were collected under standard conditions to obtain 25 microbial samples. Volunteers with no medical history aged 21-23 years were selected to participate in this study. Each individual was instructed to chew a piece of Arabic chewing gum (0.4-0.5g) for five minutes to stimulate salivary flow as much as possible then saliva was collected in sterilized screw capped bottles. The collected saliva was homogenized by vortex mixer for two minutes. Ten-fold serial dilutions were prepared using sterile normal saline. Two dilutions were selected for each microbial type and inoculated on the following culture media which are prepared according to the manufacturers instructions: 1. Mitis-Salivarius Bacitracin Agar (MSB Agar), the selective media for MS: 0.1ml was withdrawn from dilutions 10-1 and 10-2 using adjustable micropipette with disposable tips and then spread in duplicate by using sterile microbiological glass spreader on the plates of MSB agar, the plates were then incubated anaerobically by using a gas pack supplied in an anaerobic jar for 48 hrs at 37C followed by aerobic incubation for 24hrs at 37C. 2. Sabouraud Dextrose Agar (SD Agar), the medium is selective for the cultivation and isolation of C. albicans: 0.1ml was withdrawn from dilutions 10-1 and 10-2 using adjustable micropipette with disposable tips and then spread

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in duplicate by using sterile microbiological glass spreader on the plates of SD agar then the plates were incubated aerobically for 48 hrs at 37 C. A single colony from MS and C. albicans separately were transferred to 10 ml sterile BHI-B and then incubated for 24 hrs aerobically at 37C to activate the inoculums. The purity of the isolates was checked by reinoculation of 0.1 ml of the isolates from BHI-B suspensions on their selective media by spreader as mentioned before, then selective colony from each isolate was transferred to 10 ml of sterile BHI-B and incubated for 24 hrs aerobically at 37C. One ml from this broth was transferred to 10 ml sterile BHI-B and then 1 ml sterile glycerol was added to the inoculated broth; the tubes were labeled (the type of inoculum and the date of inoculation) and freezed until use. This procedure was repeated twice monthly. A colony was picked up from MSB agar and SD agar plates separately under sterilized conditions and subjected to grams stain; all the isolates were gram positive. The motility of all types of microbial cells was examined under microscope by direct smear and without staining; the isolates were non- motile. Catalase production test was performed; a small amount of pure isolates of MS cultures was transferred using a sterile loop to the surface of clean dry glass slide. Drops of hydrogen peroxide 3% immediately placed onto a portion of bacterial culture on the slide, absence of gas bubbles indicates the absence of catalase enzyme.

acid production from the fermentation reaction (Fig. 2).

Figure 2: Biochemical identification of Mutans streptococci. A: Positive control tube (agar and bacteria without mannitol). B: Study tube (agar and mannitol inoculated with MS). C: Negative control tube (agar and mannitol without bacteria).
C. albicans diagnosed according to morphological properties using Grams stain (Fig. 3) and germ tube formation in human plasma.

Figure 3: Gram's stain of C albicans showing gram positive stains (1000x magnification).
All culture media and normal saline were sterilized by autoclave at 121C and pressure of 15 pound/inch2 for 15 minutes except for the CTA medium which was sterilized by autoclaving for 10 minutes. Bacitracin solution was filtered using millipore filter size 0.20 m. Sterilization of all cleaned glass wares was conducted by hot air oven at 180C for 1 hr. Benches and floor of the laboratory were disinfected by bleaching antiseptic solution (Fas). Agar diffusion technique was applied to study the antimicrobial effects of CHX against the isolates spread on Brain Heart Infusion Agar (BHI-A); wells of equal sizes and depths were prepared in the agar using Kork porer for the evaluation of CHX. Each well was filled with 50l of 0.2% CHX. Plates left for 15 minutes in the room temperature and then incubated aerobically for 24 hrs at 37C. Inhibition zones diameters were measured using a scientific ruler.

Figure 1: MS colonies on MSB agar (20 x magnifications).


Cystine Trypticase-mannitol media had been used to test the ability of MS to ferment the mannitol which was added in a concentration of 1% to the Cystine Trypticase Agar media (which was prepared according to the manufacturer instructions biomerieux Company), then distributed into screw capped bottles (10ml in each bottle) and autoclaved, each bottle was inoculated with 0.1ml of pure MS isolates and incubated aerobically at 37C for 48 hrs. Changing in color from red to yellow indicated a positive reaction in comparison to the positive control (agar and bacteria without mannitol) and negative control (agar and mannitol without bacteria) because of pH reduction as a result of
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RESULTS
Diameters of inhibition zones for CHX were found to be greater in the plates inoculated with C. albicans than those formed in the plates of MS (Fig. 4). Students t-test showed highly significant differences among different CHX inhibitions zones (Table 1). Results of agar diffusion experiments are affected by many factors like the molecular weights and concentrations of the antimicrobial agent, the types of the isolates and the fluidity and/or stickiness of the solutions. The thickness of the agar was well controlled through out the experiment by measuring the volume of the agar while it was liquid before poring it into the same sized petridishes in order to avoid the variation of the results which will appear as a result of agar thickness variations. The size of inoculums was controlled by using adjustable micropipettes with disposable tips to ensure that equal volumes of the isolates suspensions were dispensed into all the plates and the same precaution was carried out for the volumes of the extracts and CHX which were dispensed into the wells made in the agar plates.

biological membranes like ergosterol (8). The sensitivity of MS and C. albicans to the aqueous extract of eucalyptus could be due to the hereditary contents or attraction ability or the permeability of the cell wall of the microorganisms. CHX disrupts cell membrane and cell wall permeability of many Gram- positive and Gram-negative bacteria and interferes with the adherence of plaque-forming bacteria, thus reducing the rate of plaque accumulation (9), it can inhibit the adenosine triphosphatase (ATPase) which is an important enzyme that is linked to cytoplasmic membrane and thus can inhibit the process of returning potassium ions into cells in exchange for sodium and hydrogen ions, also inhibits metabolic enzymes (10). Differences in the microbial susceptibility to CHX could also be due to the hereditary contents of the isolates which may alter the susceptibility of the organisms by modifying the targets to be attacked by the active constituents like the proteins and lipids of the microbial membrane or inhibiting the constituents of the leaves' extract or modifying the structures of these constituents by some enzymes rendering them to less effective compounds.

REFERENCES
1. Milner JL, Stohl EA, Handelsman J. A resistance gene from Bacillus cereus. J Bacteriol 1996; 178: 426672. 2. Thylstrup A, Fejerskov O. Textbook of clinical cariology. 2nd ed. Copenhagen: Munksgaard; 1994. 3. Krasse B. Caries risk: A practical guide for assessment and control. Chicago: Quintessence Publishing Co; 1985. 4. Genco, VanDyke, 1986. Quoted by Holt JG, Krieg NR, Sneath PHA, Staley JT, Williams ST. Bergey's manual of determinative bacteriology. 9th ed. Baltimore & Maryland: Williams & Wilkins; 1994. 5. Kayser FH, Bienz KA, Eckert J, Zinkernagel RM. Medical microbiology. New York: Thieme; 2005. p. 243. 6. Murphy JW, Friedman H, Bendinelli M. Fungal infections and immune responses. New York: Plenum Press; 1993. 7. Kwon-Chung KJ, Bennett JE. Medical mycology. Philadelphia: Lea & Febiger; 1992. 8. Kayser FH, Bienz KA, Eckert J, Zinkernagel RM. Medical microbiology. New York: Thieme; 2005, p 243. 9. Samaranayake L. Essential microbiology for dentistry. 3rd ed. Philadelphia: 2006. 10. Autio J. The role of chlorhexidine in caries prevention. Oper Dent 2008; 33(6): 710-6.

Figure 4: Comparison between the mean diameters of inhibition zones of CHX in relation to Mutans streptococci and C. albicans. Table1: Statistical analysis for the sensitivity of Mutans streptococci, lactobacilli and C albicans to different concentrations of aqueous extract of eucalyptus using Students t- test.
Isolates MS & C. albicans CHX 0.2% t-value t-value 16.43 0.000 ****

***P<0.001 High significant

Results showed that there were some differences in the sensitivity of the isolates to CHX; it can be explained by the differences between eukaryotic cells (fungi) and prokaryotic cells (bacteria) especially of the cell wall. The cell walls of fungi consist of nearly 90% carbohydrate (chitin, glucans, mannans) and fungal membranes are rich in sterol types not found in other
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Effect of in-dental clinic bleaching agents on the releases of mineral ions from the enamel surfaces in relation to their times intervals
Afnan AL-Shimmer, B.D.S. (1) Mohammad Al-Casey, B.D.S., M.P.H., M.S.P.H .(2)

ABSTRACT
Background: alterations of the enamel after topical application of bleaching agents, presenting as major consequences are: ions release, increased superficial roughness, stronger bacterial attachment and hardness alteration. The aims of the study were to evaluate the effects of two different types of bleaching agents for vital teeth by using with light source on the release of ions (Calcium and phosphate ions) from the enamel surface. Materials and methods: Fifty three sound enamel surface for calcium ions release and Fifty three sound enamel surfaces for phosphate ions, were subject to treated with bleaching agents (35% hydrogen peroxide and carbamide peroxide) and then application of light and laser radiation to activate the bleaching agents. Spectrophotometer and Buck scientific atomic absorption spectrophotometer were used to measure the ions release from enamel surface. Results: highly significant increase in the release of ions (calcium ions), while significant increase in the release of ions (phosphate ions) in relation to the times intervals. Conclusions: In this study showed that release of calcium ions from enamel surface after treated with both 35% carbamide peroxide and 35% hydrogen peroxide increase with increase the time and compared with release of phosphate ions release and control groups. Key word: Enamel surface, Ions release, Bleaching agents. (J Bagh Coll Dentistry 2012;24(2):91-93).

INTRODUCTION
In recent years, with more and more people interested in cosmetic enhancement, the demand of tooth bleaching is increasing sharply. Not only conventional bleaching of non-vital teeth, the needs for bleaching of vital teeth is also increase (1) Tooth bleaching can be performed externally, termed vital tooth bleaching (2) various methods and bleaching chemicals have been used extracoronally on teeth with vital pulps (3). Bleaching systems that act by means of strong oxidizers are mostly used for brightening of teeth. Depending on the form of application, the concentrations lie between 10-35% peroxide. In particular, 35% concentrated hydrogen peroxide or carbamide peroxide are used. The action mechanism is based on oxidative discoloration of incorporated colorants. However, strong oxidizers also degrade structure-relevant in the enamel (4). The most popular technique for the in-office bleaching of vital teeth involves 35% hydrogen peroxide, with phosphoric acid to facilitate bleaching and etching the teeth either a heating element or a light source to enhance the action of the peroxide (5). The use of optical radiation in the so called light assisted tooth bleaching procedure has been suggested to enhance effect of the bleaching agent (6). Many authors have demonstrated alterations of the enamel after topical application of bleaching agents, presenting as major consequences are: ions release, increased superficial roughness, stronger bacterial attachment, hardness alteration, color alteration, and adhesion to resinous materials (7) . Research in this area has showed penetration easily the hydrogen peroxide, because of its low molecular weight, passes through the enamel and dentin to the pulp(8).

MATERIALS AND METHODS


One hundred six non carious maxillary first premolar teeth extracted for orthodontic purpose. Teeth were fixed in temporary state in an auto polymerizing resin base (cold cure resin) and became ready for application. The bleaching process was done according to manufacturers instruction and this done by using a disposable brush to paint the totally cover the surface of the tooth and the time of application is 8 min and each sample three times application of pola office gel, each samples exposure to 40 second a curing light machine and Laser unit used for this study is continuous power (CW) Nd-YAG laser for exposure to the bleaching agent This step was repeated for four times for each sample as recommended by the manufacturers instructions Then the samples were washed using a continuous jet of syringe for one minute to dissolve the bleaching agent on the tooth surface and dried with air syringe for 30 seconds. Then storages in 10ml of

(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.

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de-ionized water in sterilized glass container and returned to incubator in 37 until the time of testing. Essential elements release from sample in deionized water was analyzed at the poisoning consultation centre /specialized surgeries hospital by using Buck scientific atomic absorption spectrophotometer following standardized procedure.

RESULTS
For statistical analysis was used in this study: means and standard deviation values of ions release from enamel surface that activated by two different light source and for all groups are listed in table (1).The data revealed that there was increase in ions release values for the sound enamel surface over the time for all the groups and after bleaching with both 35% carbamide peroxide and 35% hydrogen peroxide. Statistical analysis of data by using ANOVA test show in table (2) revealed that there was a non- significant difference (P>0.05) among the control groups, while highly significant difference (P<0.0001) among when use light source ( halogen light ) and also highly significant difference (P<0.0001) among the different groups when use light source (laser light) at different period of times for the release of calcium ions, while for the phosphate ions show in the table (3) revealed that there was a non-significant difference (P>0.05) among the control groups, while highly significant difference (P<0.001) among the different groups when bleaching is done using light source ( halogen light ) and also highly significant difference (P<0.001) among the different groups when use light source (laser light) at different period of times.

DISCUSSION
It is obvious from the results of this study the enamel surface when treated with 35% hydrogen peroxide gel and activated with the halogen light resulted in marked increase in the means of release of calcium ions at the 96hrs, in compared to the control groups. While result found, when treated with 35% hydrogen peroxide gel and activated with the laser irradiation for the same period of time ( 96hrs. ), found the means is higher than that of halogen light and also much higher in compared to control. This adverse effect of bleaching on the enamel mineral ( ions ) was noted by many researches, may be due to the concentration or type of the bleaching agent used, this agree with the many study (9), showed that after treatment bleaching with high concentration of hydrogen peroxide,

demineralization ( loss of mineral ) result in decreased the enamel microhardness. This may be due to higher concentration of peroxide and formed free radical is higher from laser than from halogen light, so causes more demineralization to the enamel ( Loss of calcium ions) this result agree with some study (10,11), concluded that 35% HP with light may cause significantly more loss of Ca+2 from the enamel surfaces than lower concentration CP. The treatment with carbamide peroxide and activated with laser and halogen light show in the revealed highly significant different ( P< 0.001 ) for both light source this may be indicated changes in the enamel crystal composition and alter enamel structure the result agree with other research ( 12-14) , show that bleaching with hydrogen peroxide or hydrogen peroxide releasing agents may result in significant decrease of enamel calcium and phosphate content and morphological alteration in the most superficial enamel crystallites. In this study show that carbamide peroxide causes local microstructure and chemical changes, such as loss phosphate ions, as show in the ANOVA table, represent highly significant different between the group at three period of time for the two activation used ( Halogen light and laser radiation ), this indication alteration in the composition of enamel these result agree with other result showed that in-office bleaching caused deleterious alterations in the composition and structure of enamel that significantly affected the crystalline and mineralization of the tissue(15) . In this study showed that the means of release the calcium ions from sound enamel surface is higher than the phosphate ions as showed in the table (1) this is may be due to the concentration of the calcium ions is higher than the phosphate ions in the enamel surface of permanent teeth, this result agree with many study (16, 17), Calcium ions followed by phosphorus ion were the major elements in enamel sample.

REFERENCES
1. Rodrigo A, Jose R, Hugo H, Luiz T, Rodrigo C. Effect of hydrogen peroxide topical application on the enamel and composite resin surfaces and interface Indian J Dent Res 2009; 20(1): 65-70. 2. Watt A, Addy M. Tooth discoloration and staining a review of literature. Br Dent J 2001; 190(6): 309-16. 3. Goldstein R, Garber D. Complete dental bleaching .1ste Chicago Quintessence Publishing Co Iinc.1995.ch. 1,2. 4. Nakamura T, Saito O, Kong T, Maruyama T. The effects of polishing and bleaching on the colour of discolored teeth in vivo. J Oral Rehab 2002; 28: 1080-4. 5. Goldstein R, Haywood B. Bleaching teeth: new materials-new role. J Am Dent Assoc. Quintes Int, 1992; 23: 471-88.

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6. Bruzell E, Johnsen B, Alerud T, Dahl J, Christensen T. In vitro efficacy and risk for adverse effect of light assisted tooth bleaching photochemical Photo biological Sci Dental Material 2009; 8(13): 377-85. 7. Rotstein I, Dankner E, Goldman A, Heling I, Stabholtz A, Zalkind M. Histochemical analysis of dental hard tissues following bleaching. J Endod 1996;22:23-5. 8. Oltu U, Grgan S. Effects of three concentrations of carbamide peroxide on the structure of enamel. J Oral Rehabil 2000; 27:33240. 9. Pinto C, Oliveira D, Cavalla V, Giannini M. Peroxide bleaching agents effects on enamel surface micohardness, roughness and morphology. J Braz Oral Res 2004; 18(4): 306-11. 10. Hseyin T, Ozlem S, Ferit O, Hande D, Ziya O. Effect of bleaching agents on calcium loss from the enamel surface. Quintes Int 2007; 38 (4): 339-471. 11. Bowles W, Ugwuneri Z. Pulp chamber penetration by hydrogen peroxide following vital bleaching procedures. J Endod 2001; 8: 375-7. 12. Basting R, Rodrigues A, Serra M. The effect of 10% carbamide peroxide, carbopol and/or glycerin on enamel

13.

14.

15.

16.

17.

and dentin microhardness. Opera Dent 2005; 30(5): 60816. Lee K, Kim K, Kwon Y. Mineral loss from bovine enamel by a 30% hydrogen peroxide solution. J Oral Rehabil 2006; 33(3): 229-33. Fu B, Hoth-Hannig W, Hannig M. Effect of dental bleaching on micro and macro-morphological alteration of the enamel surface. Am J Dent 2007; 20(1): 35-40. Severcan F, Gokduman K, Dogan A, Bolay S, Gokalp S. Effects of in-office and at home bleaching on human enamel and dentin: an in vitro application of fourier transform infrared study. Department of Biology. Appl Spectro Sc 2008; 62(11): 1274-9. Haitham G. Concentration of major and trace elements in permanent teeth and enamel among ( 11-14 ) years old children in relation to dental caries. A thesis submitted to the college of dentistry university of Baghdad. 2005. Justino L, Tames D, Demarco F. In situ and in vitro effect of bleaching with carbamide peroxide on human enamel. J Oper Dent 2007; 29(2): 219-25.

Table 1: Descriptive statistics of ions release from enamel surface of all groups in ppm.
Groups Control group Laser Radiation Light cure Laser radiation Times 48hours 72hours 96hours 48hours 72hours 96hours 48hours 72hours 96hours 48hours 72hours 96hours 48hours 72hours 96hours Calcium ions Mean SD 0.2480 0.0295 0.2772 0.04667 0.3350 0.01029 0.4625 0.1573 3.1812 0.4805 4.9370 0.5203 0.3187 0.2605 2.3035 0.3229 3.2870 0.4148 2.4625 0.3433 3.4862 0.3118 4.3280 0.2851 0.7110 0.0792 2.6412 0.3128 3.8240 0.5551 Phosphate ions Mean SD 0.2480 0.0295 0.2772 0.04667 0.3350 0.01029 0.6597 0.0208 2.3664 0.2732 4.1357 0.7358 0.5885 0.0788 1.7162 0.1943 2.4145 0.6644 0.7912 0.0404 1.4092 0.0949 2.7112 0.2350 0.2652 0.0609 1.3780 0.1220 1.8406 0.1030

35%CP

35%CP

35% H.P

Light cure.

35% H.P

Table 2: ANOVA test for release of ions (calcium ions ) from enamel surface at different period of time when activated with laser light and halogen light .
Agents control 35%H.P Act. With laser 35%H.P Act. With light df 2 2 2 F-test 7.450 35.323 71.868 P-values .012 .000 .000 Sig NS HS** HS*

Table 3: ANOVA test for release of ions ( phosphate ions ) from enamel surface at different period of time when activated with laser light and halogen light .
Agents control 35%H.P Act. With laser 35%H.P Act. With light df 2 2 2 F-test 7.450 174.887 269.106 P-values .012 .000 .000 Sig NS HS** HS*

HS = Highly significant different (p< 0.0001). NS = Non signifiant different (p>0.005).

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Physicochemical characteristic of unstimulated and stimulated saliva with different chewing gum stimulation
Alhan A. Qasim, B.D.S., M.Sc. (1) Eman K. Chaloob, B.D.S., M.Sc. (1)

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

INTRODUCTION
Chewing gum probably has its origin in ancient Egypt and in Mayan Indian times as these peoples are known to have chewed the resin of trees(1)also, in 50A.D.,when the Greeks sweetened their breath and cleansed their teeth with arsine called mastiche, which was obtained from the bark of the mastic tree so that the chewing gum first became an aid to maintaining oral health(2),in addition to that chewing gum increases salivary flow rate and enhance the protective properties of saliva this because the concentration of bicarbonate and phosphate is higher in stimulated saliva, and the, resultant increase in plaque pH and salivary buffering capacity prevent demineralization of tooth structure. Morevere, the higher concentration of calcium, phosphate, and hydroxyl ions in such saliva also enhances (3,4) remineralization .Many studies have demonstrated the ability of mastic gum to suppress the growth of cariogenic bacteria and to reduce the salivary streptococcus mutans count(5),as well as another study concept that the use of mastic gum and xylitol containing chewing gum for 20 minutes after an acidogenic challenge can enhance the remineralizing potential of the mouth, probably by stimulating salivary flow (6), also a study by Bakhtiari (7)compared the rate of
(1) Lecturer. Pediatric and Preventive Department. College of dentistry, University of Baghdad.

the secreted saliva and its pH after chewing xylitol-containing gum and mastic gum in case and control groups.The results indicated that both mastic gum and xylitol chewing gum increased the rate of secreted saliva and its pH (7), Another important sugar free gum was Acacia gum consists primarily of Arabica, a complex mixture of calcium, magnesium and potassium salts of Arabic acid. It contains tannins which are reported to exhibit astringent, homeostatic and healing properties. It also contains cyanogenic glycosides in addition to several enzymes such as oxidase, peroxides and pectinases, all of which have been shown to exhibit antimicrobial properties. Acacia Arabica type of chewing gum has potential to inhibit early plaque formation (8). On other hand most chewing gum is sweetened with sucrose, gum products may increase the cariogenic load to dietary carbohydrates (9). The aim of the present study was to investigate the effect of different chewing gums on the salivary constituents including some elements (Magnesium, Calcium, Copper and Zinc), PH and flow rate.

MATERIAL AND METHODS


The sample of present study composed 80 dental students (college of dentistry, university of Baghdad) aged 23 years, they were divided in to four groups, each group consist of 20 sample, The saliva was collected after taking the medical

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history and any medical problems or any systemic diseases were excluded. The collection of stimulated salivary samples was performed under standard condition following instruction cited by (10) , while the collection of unstimulated salivary samples was performed under standard condition following instruction cited by Tenovuo and Lagerlof (11) First group the individuals were asked to collect unstimulated saliva. Second group the individual were asked to chew a piece of Mastic chewing gum. Third group the individual were asked to chew a piece of Arabic gum. Fourth group the individual were asked to chew sugar gum. For these entire 4 groups the chewing was for one minute all saliva was removed by expectoration, chewing was then continued for ten minutes with the same piece of chewing gum and saliva collected in a sterile screw capped bottle. Salivary pH was measured using an electronic pH meter and flow rate of saliva was expressed as milliliter per minute (ml/min).The salivary samples were then taken to the laboratory for biochemical analysis. Samples were centrifuge by (Gallen kamp, England) at 3000 rpm for 30 minutes; the clear supernatant was separated by disposable micropipette and was divided into 4 portions, stored at (-20C) in a deep freeze till being assessed. Biochemical analysis of four elements of saliva (Calcium, Magnesium, Copper, Zinc) were done at the Poisoning Consultation Centre / specialized surgeries hospital by flame atomic, using absorption spectrophotometer (Buck scientific, 210VGP, USA) following standardized procedure. 1. Determination of Ca++ :Dilute the samples in four groups with the lanthanum diluents, mix well and take for measurement of calcium by atomic absorption spectrophotometer (AAS)10.a hollow cathode lamp specific for calcium was used at a wave length of 422.7nm. 2. Determination of (Magnesium, Copper, Zinc): the samples in four groups were diluted with deionised water mix well and take for measurement of these elements by atomic absorption spectrophotometer (AAS)(12). The data was processed with SPSS 9.0 statistical software. ANOVA (analysis of variance), LSD test and Student's t-test served for statistical analyses. The significance level was set at 95% (P<0.05).

difference in salivary pH among different type of chewing gum stimulation ,while the difference were not significant, concerning flow rate. Further investigation using L.S.D test revealed that there is no significant difference between salivary pH, flow rate with different chewing gum stimulation Table 2 .The pH of unstimulated saliva was found in the present study to be 6.80556 which was lower that for stimulated saliva with different type of chewing gum and this difference were highly significant for Arabic and sugar chewing gum (-2.958, -3.039) Table (3), this table also revealed the salivary flow rate for unstimulated saliva was lower than for stimulated saliva with different chewing gum but these difference were not significant. Table (4) shows that there is highly significant difference in concentration of Mg, Ca, Cu among different type of chewing gum, while salivary Zinc concentration the difference was not significant..Further investigation using L.S.D test showed that salivary concentration of Mg, Ca and Cu were found significantly higher among group with mastic than Arabic chewing gum stimulation, while opposite figure found concerning salivary concentration of Zinc with significant difference. The L.S.D test also shows that the concentration of salivary Mg, Ca were highly significant, higher among group using mastic chewing gum than that using sugared chewing gum and opposite figure was found concerning concentration of copper as its concentration were highly significant ,higher among group using sugar chewing gum than group using mastic chewing gum Table 5, this table also revealed that the only significant difference was found concentration of salivary copper where company its concentration between person using sugar stimulation. Salivary Mg , Ca, Cu, Zn (mean and SD) among unstimulated and stimulated saliva were shown in table 6 that show the mean of salivary Mg, Ca was higher in mastic chewing gum stimulation than that for unstimulated saliva and these difference were highly significant (-7.610, -8.174), also this table revealed that the mean of salivary Cu was higher concentration in sugar and mastic gum stimulation than that for unstimulated saliva with highly significant difference(-3.023, -11.071), while significantly salivary Zn concentration was higher in Arabic chewing gum than that for unstimulated saliva(-2.413).

DISCUSSION
Chewing gum use has a longer period of exposure to the surface of teeth than a dentifrice or mouth rinse; therefore it can be a useful adjunct for maintaining oral health, especially if it contains a therapeutic agent that is effective topically(13).In

RESULTS
The mean values of salivary pH ,flow rate for different type of chewing gum stimulation were shown in table 1that shows highly significant
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the present study the pH ,flow rate and some salivary elements of three types of chewing gum and unstimulated saliva was assessed. The present study represented that the pH mean of unstimulated saliva group was found to be lower than other groups with highly significant difference, this may be due to that there is a consequent rise in pH level which reaches a peak (7.6-7.8) after 3-5 minutes of chewing to a level above the critical pH and this agree with previous studies (14,15) Although both sucrose containing and sugar-free gum stimulate salivary flow (9),the higher mean of flow rate was found in 3rd group(sugar chewing gum ) in this study with no significant difference between groups of chewing gum and unstimulated saliva, , this may be due to a combined effect of gustatory stimulation from the sweetening and flavoring agents and mechanical stimulation of salivary flow from chewing (16). Concerning salivary elements the result showed that Mg and Ca ions significantly high in mastic gum group comparing with other groups ,this could be due that the use of chewing gum increases salivary flow rate and enhances the protective properties of saliva. Moreover, the higher concentration of calcium, phosphate, and hydroxyl ions in such saliva also enhances remineralization(1,3).Furthermore, saliva maintains the integrity of the teeth, because ions such as calcium, phosphate, magnesium, and fluoride can diffuse into enamel (17), Regarding calcium, phosphate and zinc ions different previous studies reported a significant role of these elements in relation to increase resistant of teeth to dental caries. Their presence in saliva may enhance remineralization and increase resistant of the outer enamel surface to acid dissolution (18,19,23),thus establishing a natural remineralization process as these ions increases with increas of salivary flow rate .In the present study the mean of Zn ione was significantly high in Arabic gum group this agree with Al Saadi (20), moreover Acacia gum consists primarily of Arabica, a complex mixture of calcium, magnesium and potassium salts of Arabic acid. It contain tannins which are reported to exhibit astringent, homeostatic and healing properties (9).as well as Zinc and Copper are important for the healthy periodontal tissue as they effect on the collagen production (21,22).Finally the results of the present study support the concept that use o1f chewing gum especially mastic and Arabic(natural gum) can enhance the remineralizing potential of the mouth, probably by stimulating salivary flow which may lead to rise salivary elements. Since this is the first study on the effect of different chewing gums on the some salivary elements also
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a necessity to investigate the effectiveness of this natural product through long-term clinical.

REFERENCES
1. Imfeld T. Chewing gumfacts and $ction: a review of gum chewing and oral health. Crit Rev Oral Biol Med 1999; 10:405-19. 2. Cloys LA, Christen AG, Christen JA. The development and history of chewing gum. Bull Hist Dent 1992; 40:57-65. 3. Saliva: its role in health and disease. Working Group 10 of the Commission on Oral Health, Research and Epidemiology (CORE).Int Dent J 1992; 42(4 Suppl 2):287-304. Erratum in: Int Dent J1992; 42:410. 4. Szke J, Bnczy J, Proskin HM. Effect of aftermeal sucrose-free gum-chewing on clinical caries. J Dent Res 2001; 80(8):1725-9. 5. Aksoy A, Duran N, Koksal F. In vitro and invivo antimicrobial effects of mastic chewing gum against Streptococcus mutans and mutans streptococci.Arch Oral Biol 2006; 51(6): 476-81. 6. Biria M, Malekafzali B, Kamel V. Comparison of the Effect of Xylitol Gum- and Mastic chewing on the Remineralization Rate of Caries-like Lesion. Journal of Dentistry, Tehran University of medical Sciences, Tehran, Iran 2009; 6(1): 6-10. 7. Arfa M, Bakhtiari S. Effect of chewing mastic gum and a xylitol chewing gum on the PH and flow rate of saliva, PhD [thesis]. Tehran: Dentistry Faculty of Shahid Beheshti University of Medical Sciences; 2003-2004. 8. Gazi M. The finding of antiplaque features in acacia Arabica type of chewing gum. J Clin Periodontal 1991; 18:75-77. 9. Kahtani D .Chewing gum: Trick or treat? The Saudi Dental Journal 1999;11(1): 27-34 10. Tenovuo J and Legerlof F. Saliva. In: Thylstup A., and Fejerskov O. ed. Textbook of Clinical Cariology. 2nd ed. Munksgaard: Copenhagen; 1996. 11. Tenovuo J, Lagerlof F. Saliva . In Textbook of clinical cariology etd. By thylstrup A and Fejerskov O. 2nd ed. Munksgaard, Copenhagen, 1994.p.17-43. 12. Haswell SJ. Atomic absorption spectrometry theory, design and application.Elservier, Tokyo. 1991. 13. Sanares AM,King MK,Itthagarun A,MingWong H.Chewing gum as amedium for the delivery of anticariogenic therapeutic agents: a review. Hong Kong Dent J 2009; 6:13-22. 14. Jason M. Xylitol chewing gum & dental caries. Int Dent J 1995; 45:65-76. 15. Al Zaidi WH. Oral Immune Factors and Salivary Contituents in Relation to Oral Health Status among Pregnant Women. Ph.D. Thesis, College of Dentistry, University of Baghdad, 2007. 16. Jensen M. Effect of chewing sorbitol gum & paraffin on human interproximal plaque pH. Caries Res 1986; 20:503-509. 17. Margolis HC, Moreno EC. Kinetics of hydroxyapatite dissolutionin acetic, lactic, and phosphoric acid solutions. Calcif Tissue Int1992; 50:137-43. 18. EL-Samarrai SK. Major and trace elements of permanent teeth and saliva among a group of adolescent, in relation to dental caries, gingivitis and mutans streptococci. A Ph.D. Thesis, College of Dentistry, University of Baghdad, 2001.

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19. Palmer CA. Nutrition, diet and oral conditions. In: Primary preventive dentistry. By Harris N.O., Christen A.G.4th ed. Appleton and Lange 1995. 20. Al-Saadi AA. Oral Health Condition and Salivary Constituents (Zinc,Copper,Calcium,Iron,Total Protein) among the selected Overweight Primary School Children. Msc thesis submitted to the College of Dentistry, University of Baghdad. 2008 21. Curzon ME, Cutress TW. Trace elements and dental disease. John wright. PSG Inc. England. 1983, 545,p 107-115.

22. Al- Safi KH. Biochemical, Immunological and Histo chemical study of Cyclosporine- A induced gingival enlargementin kidney Transplanted patients. Doctor thesis submitted to the College of Dentistry, University of Baghdad. 2007. 23. Jawed M, Shahid SM, Qader SA, Azhar A. Dental Caries in diabetes mellitus role of salivary flow rate and minerals. Journal of Diabetes and Its Complications 2011; 25(3): 183-186. IVSL (Iraq Virtual Science Library).

Table 1: Salivary pH and flow rate (Mean SD) among different chewing gum simulation
Variables pH Flow rate Mastic Gum Arabic Gum Suger Gum Mean SD Mean SD Mean SD 7.100 .458 7.275 .454 7.245 .345 2.910 1.208 2.855 1.234 3.420 1.323 Highly significant p< 0.01 ANOVA F Sig 4.464* .006 1.369 .259

Table 2: Salivary magnesium, calcium, copper and zinc (Mean SD) among different chewing gum stimulation
Variables Magnesium Calcium Copper Zinc Mastic Gum Mean SD 4.593 2.242 15.200 5.207 53.500 13.869 16.000 9.403 Arabic Gum Mean SD .338 .212 4.580 1.477 25.500 6.863 21.500 8.127 Suger Gum Mean SD .455 .156 3.190 .748 75.000 10.000 15.500 7.591 ANOVA F Sig 62.509* .000 70.657* .000 83.572* .000 2.540 .063

Table 3: LSD test of PH and flow rate among different chewing gum stimulation
pH Flow rate Mastic &Arabic Gum Mean Sig -.175 .232 .055 .893 Mastic &Suger Gum Mean -.145 -.510 Sig .322 .216 Arabic &Suger Gum Mean .030 -.565 Sig .837 .171

Table 4: LSD test of salivary electrolytes among different chewing gum stimulation
Magnesium Calcium Copper Zinc Mastic &Arabic Gum Mean 4.225* 10.620* 28.000* -5.500* Mastic &Suger Gum Sig Mean .000 4.138* .000 12.010 * .000 -21.000 * .037 .500 Highly significant p< 0.01 Sig .000 .000 .000 .848 Arabic &Suger Gum Mean .117 1.390 49.000* 6.000* Sig .745 .140 .000 .024

Table 5: Salivary Ph and flow rate among unstimulated saliva and stimulated salivary groups
Variables pH Unstimulated mean SD Stimulated Mean SD t-test 1 7.100 .458 -1.861 6.800 .556 2 7.275 .454 -2.958* 3 7.245 .345 -3.039* 1 2.910 1.208 -.716 2.615 1.391 2 2.855 1.243 -.575 3 3.420 1.323 -1.875 *Highly significant p<0.01 Sig .071 .005 .004 .478 .569 .069

Flow rate

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

and stimulated

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Dynamic lip to tooth relationship during speech, posed and spontaneous smile using digital videography
Ali S. Al-khafaji, B.D.S. (1) Nagham M. Al-Mothaffar, B.D.S., M.Sc. (2)

ABSTARCT
Background: The human face is a living mirror held out to the world. Natural, marked, painted or adorned, it has power to attract, charm, captivate or brighten. Therefore the subject of the smile and facial animation, as they relate to communication and expression of emotion, should be of great interest to orthodontists so the aims of this study were to determine the difference of outer commissure width, inter-labial gap, smile index, modified smile index, visible maxillary interdental width, buccal corridor percentage and maximum incisor show among different smile styles (Monalisa, Cuspid and complex) during emotion, posed smile and speech. And to determine the differences of the same variables for each smile style among emotional smile, posed smile and speech. Materials and methods: The sample consisted of 77 Iraqi adult subjects (18-30) years with skeletal class I occlusion, classified into three categories according to a certain neuromuscular mechanism of smile called smile style, the first group consisted of 34 (24 male, 10 female) subjects with Monalisa smile style, the second consisted of 34 (22 male, 12 female) subjects with Cuspid smile style, the last 9 subjects (5 male, 4 female) were the third group with Complex smile style. Each subject was recorded using digital videographic camera while watching a comical movie to elicit emotional smile, then they asked to say Chelsea eats cheesecake to record them during speech. The videographs were imported to the PMB-picture motion browser to capture emotional smile, posed smile and speech frames. Four linear measurements were measured for each frame using AutoCAD program 2011. Results: The results of this study showed that all the variables changed significantly when the subject change from speech to emotional smile frame in all smile styles. And these changes revealed almost the same behavior when the subject changed from speech to pose or to emotional smile frames. Conclusion: The result of this study revealed that emotional smile is largely different from posed smile in different aspects which has an effect on decisions related to orthodontic diagnosis and treatment plan. Keywords: smile style, emotional smile, posed smile, digital videography. (J Bagh Coll Dentistry 2012;24(2):99-103).

INTRODUCTION
Obtaining a beautiful smile is always the main objective of any aesthetic dental treatment. Therefore, it is essential to control the esthetic effects caused by orthodontic treatment, which is only possible by knowing the principles that manage the balance between teeth and soft tissues during smile (1); as the presence of a malocclusion has a negative impact on facial attractiveness and orthodontic correction of a malocclusion affects overall facial esthetics positively (2). After all, it is the beauty of the smile that will make the difference between an acceptable or pleasing aesthetic result for any given treatment (3).Smiles can be either posed or spontaneous (4), the posed, false, or social smile which is voluntarysmile and does not need an emotion to be accomplished. A posed smile is static in the sense that it can be sustained (5). When posing for a photograph a person uses the social smile in social setting (6). In treating the smile, the social smile generally represents a repeatable smile (7). However, the social smile can mature and might not be consistent over time in some patients (8). The unposed, spontaneous, enjoyment or real smile is involuntary and represents the emotion that persons are experiencing at that moment. Therefore it has many descriptions, such as laughing, cry, knowing or insipid (9). It is dynamic in the sense that it bursts forth but is not sustained.Emotional backgrounds influence a voluntary posed smile (10), A well-known phenomenon in clinical practice is that patients guard their smiles because of dissatisfaction with them. When asked for a posed smile, they show only what they consciously or subconsciously want to present (11).Another example of interfering emotional factors on the posed smile is feelings of shame by victims of undisclosed childhood sexual abuse. Their social smiles appeared to be considerably less expressive; sospontaneous smiling is a logical focus point in smile diagnostics (12). This is in line with recommendations of oral surgeons and esthetic dentists (13) .Smile style is another soft-tissue determinant of the dynamic display zone. There are three styles: the cuspid smile, the complex smile, and the Mona Lisa smile. An individuals smile style depends on the direction of elevation and depression of the lips and the predominant muscle groups involved. The cuspid or commissure smile is characterized by the action of

(1) M.Sc. student, dep. of Orthodontics, college of dentistry, university of Baghdad (2) Professor, dep. of Orthodontics, college of dentistry, university of Baghdad

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all the elevators of the upper lip, raising it like a window shade to expose the teeth and gingival scaffold. The complex or full-denture smile is characterized by the action of the elevators of the upper lip and the depressors of the lower lip acting simultaneously, raising the upper lip like a window shade and lowering the lower lip like a window. The Mona Lisa smile is characterized by the action of the zygomaticus major muscles, drawing the outer commissures outward and upward, followed by a gradual elevation of the upper lip. Patients with complex smiles tend to display more teeth and gingiva than patients with Mona Lisa smiles (14).

MATERIALS AND METHODS


The sample of the study composed of 77 Iraqi adult subjects in an age group of 18-30 years with skeletal class I occlusion.The sample was classified into three groups according to smile style as the following:Monalisa group composed of 34 subjects (24 male and 10 female), Complex group composed of 9 subjects (5 male and 4 female), Cuspid group composed of 34 subjects (22 male and 12 female).This classification was done depending on the direction of elevationand depression of the lips and the predominant muscle groups involved.The video recordings for each group were made in a setup consisting of a chair with a digital video camera and television set (laptop connected to the screen). The television screen was placed at eye level. When the visual axis will be horizontal, the subjects will keep their heads mainly in a natural head position(15). The video camera was adjusted to the subjects mouth level at a 55-cm distance and continuously registering the face as shown in figure 1.

To prompt emotional smiling, the subjects watched television fragments of practical jokes downloaded from the website of videos you tube the funniest Iraqi practical jokes. The subjects will be unaware of the exact aim of the study. While watching the television, the subjects wear glasses with a clipped-on reference standard to enable calibration in a digital measurement program. In this way, a maximum emotional smile (emotional smile frame) will be recorded with minimal intrusion of the subject (16).By using the same technique for obtaining natural head position in emotional smile capture, the subject was asked to read a sentence appeared on the screen made by a power point slide, this sentence was Chelsea eats cheesecake to capture him\her saying the syllable chee (speech frame). The subject was asked to relax, and then smile to capture the posed smile (posed smile frame).Firstly, the videographs were imported to the PMB- picture motion browser. This software enables the operator to save a movie as an image sequence and then export roughly 24 frames per second. Each frame could be saved identical in size and resolution (17).To extract frame from video recording of speech, a video converter computer software was used to split the second in which the subject saying the syllable chee in the word cheesecake into 30 frames or more in persons who pronounced the word very fast.In addition to high quality video recording mode (HQ MODE) the photos (frames) extracted from the video clips were treated with another software which was the photozoom pro 3 to improve image quality while zooming in AutoCAD program 2011. Finally, smile frame was imported to the AutoCAD program. Magnification correction was done in reference to the glasses with the attached ruler, so that the real measurements were obtained. After that, landmarks were identified and measurements were determined (Figure 2).

Figure 1: Standardization of the videogragh Figure 2: Linear measurements during emotional smile
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RESULTS
The sample is classified into three groups, each group captured in three frames: speech, posed and emotional smile frames.Comparison among different smile styles for each frame is done first, to compare among different smile style during emotional smile,analysis of variance (ANOVA test) was performed to identify the presence of significant differences for the measured variables. As shown below (Table 1) there was a significant difference in all the variables measured except for outer commissure width.

Finally maximum incisor show (MIS) was only significantly higher in Cuspid group than Complex group, but insignificantly higher in Monalisa than Complex group. The same method is used to compare among different smile styles in speech and posed smile frames. Comparison among different frames for each smile style is also done by ANOVA test for Monalisa group in different frames (emotional, posed, and speech frame) as revealed in Table 3.

Table 1: ANOVA test for emotional smile among different smile style.
Variable OCW ILG SI MSI VIW BCP MIS F 0.320 12.45 13.90 12.47 21.66 30.89 3.657 p-value 0.727 .000 .000 .000 .000 .000 0.03 Sig Ns *** *** *** *** *** **

Table 3: ANOVA test for Monalisa group in different frames


Variable OCW ILG SI MSI VIW BCP MIS F 20.94 45.87 11.88 12.65 80.08 32.68 30.89 p-value .000 .000 .000 .000 .000 .000 .000 Sig *** *** *** *** *** *** ***

The LSD test (Table 2) was used to detect statistically significant difference between every two groups for the significant different variable found in ANOVA test (Table 1), Interlabial gap (ILG) and modified smile index (MSI) were significantly higher in Cuspid group when compared with Monalisa and Complex groups, while smile index (SI), visible intermaxillary width (VIW) and buccal corridor percentage (BCP) was significantly higher in Monalisa and Complex groups than in Cuspid group.

The LSD test revealed that all variables shows significant difference between every two frames except for smile index (SI) and modified smile index (MSI) between posed smile and speech which were insignificantly differ from each other. Again the same statistical analysis is used to compare the other smile styles (Cuspid and Complex) in different frames.

DISCUSSION
The age of the sample ranged from 18 to 30 years because adolescents undergo a maturational sequence in learning how to smile (18) and on the other hand all dynamic measurements of the smile decrease with age especially after ages 30 to 39 years (19). In addition in this study, there was no need to differentiate between genders (16). Firstly, Emotional smile in each smile style:the Interlabial gap (ILG) was significantly higher in Cuspid group than Monalisa and Complex groups, this increase may be due to the dominance of the levatorlabiisuperioris musclein Cuspid group exposing more attached gingivae above the maxillary anterior teeth than the other groups and thus increasing Interlabial gap this comes in agreement with the explanation of Phillips in 1999.The same reason mentioned above was responsible for significant increase in modified smile index (MSI) and decreased smile index (SI) for Cuspid group over the other groups because they depend on Interlabial gap (ILG). This come in agreement with Ackerman and Ackerman (2002); Sarver and Ackerman (2003b) who found

Table 2: LSD for emotional smile frame among different smile style
SMILE STYLE P SIG Monalisa Cuspid .000 *** ILG Monalisa Complex .635 NS Cuspid Complex .009 * Monalisa Cuspid .000 *** SI Monalisa Complex .846 NS Cuspid Complex .003 ** Monalisa Cuspid .000 *** MSI Monalisa Complex .894 NS Cuspid Complex .002 ** Monalisa Cuspid .000 *** VIW Monalisa Complex .465 NS Cuspid Complex .000 *** Monalisa Cuspid .000 *** BCP Monalisa Complex .946 NS Cuspid Complex .000 *** Monalisa Cuspid .052 NS MIS Monalisa Complex .273 NS Cuspid Complex .020 * Orthodontics, Pedodontics, and Preventive Dentistry101 Var.

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any increase in interlabial gap leads to decrease in smile index and any increase in outer commissure width leads to increase smile index. For visible maxillary interdental width (VIW) of Complex group showed statistical significant increase from Cuspid and statistical nonsignificant increase from Monalisa groups, this may be due to the fact that in Complex group the shape of the lips are typically illustrated as two parallel chevrons, the levators of the upper lip, the levators of the corners of the mouth, and the depressors of the lower lip contract simultaneously, showing all the upper and lower teeth concurrently showing more area of upper teeth than the other groups, this comes in line with the conclusion Phillips 1999.For buccal corridor percentage (BCP) the same explanation can be given to significant increase of Complex group compared with Cuspid group because buccal corridor percentage (BCP) depends on visible maxillary interdental width (VIW).Finally the Cuspid group showed significant increase in maximum incisor show (MIS) than Complex group, also may be due to that the vertical distance between upper left central incisor incisal edge and upper lip margin increased, this comes in agreement with the findings of Phillips in 1999(20), who reported that the maximum incisor show increased in Cuspid group. Speech in each smile style had a different liptooth characteristics, Although the main muscle responsible for the morphological change in lips during saying cheese is the orbicularis oris muscle, it may be affected by the specific neuromuscular mechanism of each smile style because the levatorlabiisuperiorus muscle have the medial slip inserted into the orbicularis oris muscle(21). Also in a study of electromyography (EMG) of human lip muscle done by Blair and Smith (22), they found that even with intramuscular electrodes, the probability of recording from a single muscle of the lip during speech is extremely low. So the interaction of muscle of facial expression during speech could explain why even with speech each smile style have different lip-tooth relationships.The explanations of significant increase or decrease of different variable during speech among different smile styles may resemble those of emotional or posed smile patterns probably because of interfering facial muscle as discussed above. Monalisa smile style in each frame: Firstly the outer commissure width (OCW) was greater with highly significant level in emotional smile than posed one, this finding supports the conclusion of Van der Geld et al. in 2008(23)who noticed the
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significant reduction in inter-commissure distance (smile width) of posed smiling compared to emotional smiling.The statistical significant increase of interlabial gap (ILG) of emotional smile over posed one may result from mouth opening and increase in the mandibular anterior tooth display during emotional smile.The statistical significant decrease of interlabial gap (ILG) of speech when compared with posed smile comes in disagreement with Ackerman et al. in 2004 who found insignificant increase of Interlabial gap (ILG) of speech when compared with posed smile.The statistical significant increase of visible maxillary interdental width (VIW) of emotional smile when compared with other frames may be as a result of exposing the 2nd premolar and 1st molar during emotional smiling than during posed smiling. The result of this study revealed that emotional smile is largely different from posed smile in different aspects which has an effect on decisions related to orthodontic diagnosis and treatment plan.The outer commissure width and visible maxillary interdental width that compose the buccal corridor percentage, as we know the smaller the buccal corridor the greater the esthetic appearance, and in posed smile the buccal corridor is significantly lower than in emotional smile, so the dependence on buccal corridor percentage (BCP) of posed smile can lead to inadequate diagnosis and treatment plan regarding arch width, smile arc and transversal occlusal plane.This comes in agreement with Van der Geld et al., in 2008who stated that as a result of reduced smile width during posed smiling, the buccal corridors can be underestimated and upper arch widening not deemed to be needed during orthodontic or surgical treatment.The maximum incisor show was significantly higher in emotional smile than posed, in another words the lip line height is appeared too low in posed smile particularly in the case of gummy smile patients, who have the muscular ability to raise the upper lip significantly higher than average on smiling emotionally. Again it was the posed smile smaller measurement that may give us the errors in estimation of gummy smile, and subsequently decisions of intrusion of maxillary anterior teeth versus surgical intervention to correct the problem becomes a matter of controversy.

REFERENCES
1. Ritter DE, Gandini JR, Santos Pinto AD, Locks A. Esthetic Influence of Negative Space in the Buccal Corridor during Smiling. Angle Orthod 2006; 76(2):198203.

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2. Rodrigues CD, Magnani R, Machado MS, Oliveira OB. The Perception of Smile Attractiveness. Angle Orthod. 2009; 79:6349. 3. Camara CA. Aesthetics in Orthodontics: Six horizontal smile lines. Dental Press J Orthod 2010; 15 (1):118-31. 4. Peck S, Peck L. Selected aspects of the art and science of facial esthetics. Semin Orthod 1995; 1(2): 10526. 5. Hulsey CM. An esthetic evaluation of lip-teeth relationships present in the smile. Am J Orthod. DentofacialOrthop 1970; 57:132144. [Cited by Ackerman MB, Brensinger C, Landis JR. An evaluation of dynamic lip-tooth characteristics during speech and smile in adolescents. Angle Orthod 2004; 74:4350. 6. Sarver D.M. The Face As Determinant of Treatment Choice, In: Frontiers of Dental and Facial Esthetics Craniofacial Growth Series Center for Human Growth and Development. Ann Arbor: University Of Michigan 2001a, 38:19-54. 7. Rigsbee OH, Sperry TP, Begole E. The influence of facial animation on smile characteristics. Int J Adult OrthodOrthognathSurg 1988; 3(1): 233-9. 8. Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: Part 1. Evolution of the concept and dynamic records for smile capture. Am J OrthodDentofacOrthop 2003 a; 124(1): 4-12. 9. Duchenne de Boulogne GM. The Mechanism of human facial expression. Cambridge, United Kingdom: Cambridge Univ. Press 1990, p.167. 10. Otta E, FolladoreAbrosio F, Hoshino R. Reading a smiling face: messages conveyed by various forms of smiling. Percept Mot Skills 1996;82:1111-21. (Cited by: Van der Geld et al. Digital videographic measurement of tooth display and lip position in smiling and speech: Reliability and clinical application. Am J Orthod Dentofacial Orthop 2007 b; 131:301.e1-301.e8. 11. Moskowitz M, Nayyar A. Determinants of dental esthetics: a rationale for smile analysis and treatment. Compend Contin Educ Dent 1995; 16:1164-6. (Cited by: Van der Geld et al. Digital videographic measurement of tooth display and lip position in smiling and speech: Reliability and clinical application. Am J Orthod Dentofacial Orthop 2007 b; 131:301.e1-301.e8).

12. Bonanno GA, Keltner D, Noll JG, Putnam FW, Trickett PK, LeJeune J, et al. When the face reveals what words do not: facial expressions of emotion, smiling, and the willingness to disclose childhood sexual abuse. J Pers Soc Psychol 2002;83:94-110. 13. Allen E, Bell W. Enhancing facial esthetics through gingival surgery. In: Bell WH, editor. Modern practice in orthognathic and reconstructive surgery. Philadelphia: Saunders; 1992. p. 235-51. 14. Ackerman MB, Ackerman JL. Smile analysis and design in the digital era. J Clin Orthod 2002; 36(4): 221-36. 15. Rosetti Y, Tadary B, Pablanc C. Optimal contributions of head and eye positions to spatial accuracy in man tested by visually directed pointing. Exp Brain Res 1994; 97:487-96. (Cited by: Van der Geld et al. Digital videographic measurement of tooth display and lip position in smiling and speech: Reliability and clinical application. Am J Orthod Dentofacial Orthop 2007 b; 131:301.e1-301.e8. 16. Van der Geld P, Oosterveld P, van Waas M A, Kuijpers-Jagtman AM. Digital videographic measurement of tooth display and lip position in smiling and speech: Reliability and clinical application. Am J Orthod Dentofac Orthop 2007 b; 131:301.e1-301.e8. 17. Maulik C, Nanda R. Dynamic smile analysis in young adults. Am J Orthod Dentofac Orthod 2007; 132(3):307-15. 18. Ackerman JL, Ackerman MB, Brensinger CM, Landis JR. A morphometric analysis of posed smile. Clin Orthod Res 1998; 1(2): 2-11. 19. Desai S, Upadhyay M, Nanda R. Dynamic smile analysis: Changes with age. Am J Orthod Dentofac. Orthop 2009; 136(3): 310-1. 20. Philips E. The classification of smile patterns. J Can Dent Assoc 1999; 65(5): 252-4. 21. Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. Dermatology: 2-Volume Set. St. Louis: Mosby 2007, pp. 2166. 22. Blair C, Smith A. EMG recording in human lip muscle. Journal of Speech and Hearing Res 1986, Vol.29 256-266 June. 23. Van der Geld P, Oosterveld P, Berge SJ. and Kuijpers A.M. tooth display and lip position during spontaneous and posed smiling in adults. Informa UK Ltd 2008 a; 66: 207-13.

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Dental caries in relation to oral infections and feeding types among children aged 2-5 years
Aseel H. M.J. Al-Assadi, B.D.S., M.Sc. (1)

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

INTRODUCTION
Dental caries is one of the most prevalent chronic disease(1) commonly affect children(2),it still holds the highest prevalence and severity among other dental problems. The caries process can develop as soon as the tooth erupted in the oral cavity(3).It is regarded as an infectious, contagious and multifactorial disease produced by three primary individual factors: cariogenic microorganisms, cariogenic substrate and susceptible host (or tooth)(4). These factors interact in a certain period of time causing an imbalance in the demineralization and remineralization between tooth surface and the adjacent plaque (5). The oral cavity of neonates is germ free or contains the same microorganisms of the vagina, which will decrease in number few days after birth and will be readily changed by child caretaker microorganisms(6) . Thus the cariogenic microorganisms can be transmitted to the infant and caries development may be favored (7), that transmission may be vertical transmission from caregiver to child and the major reservoir from which infants acquire those microorganisms is their mothers (8,9) or the horizontal transmission (between members of a group e.g. family members of a similar age or students in a classroom) (10).
(1)Lecturer, Department of Pedodontics and Preventive Dentistry, College of Dentistry, University of Baghdad

The most important factor in the determination of child medical and dental health is the family. This may be due to the fact that family, especially the mother, greatly influences the health related behavior of the child (11,12). Most of mothers had very little knowledge on how important breast milk is for a childs health and, till now, the delivery of formula milk is expected to replace the role of breast milk providing nutrition for infants which contains very high sugar and low on other nutrition elements (3). Concerning infants feeding methods, prolonged and exclusive breast-feeding has been associated with many health benefits, including reduced risks of gastrointestinal and respiratory infection, atopic eczema and other allergic diseases, and improved neurocognitive development(13), while bottle fed children are more prone to frequent infections such as oral thrush, acute otitis media and upper respiratory tract infections(14).There are many studies found that bottle fed children are more likely to develop dental caries than their breast fed counterparts (1518) ,but others found no significant relation(8,19) . Oral health is one component of general health and is an important factor in the normal development of a child. Oral health problems or illnesses can influence the general development of a child and its general health and can adversely affect quality of life (20). However, there is no available previous Iraqi study concerning the relation between dental

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caries and oral infections. So this study was an attempt to determine this relation according to feeding habits and types of microorganisms found in the oral cavity among group of children aged 25 year old.

Statistical analyses were performed using SPSS package version 16. Students t-test was applied for comparisons between the caries free and caries active group. (P < 0.05) was considered statistically significant.

MATERIAL AND METHODS


Twenty two children with no history of any systemic diseases aged 2-5 years were participated in the present study (study group). All of them were with full set of primary dentition and had dental caries. The control group composed of 22 caries free children matching the study group in age and gender. A consent form obtained from the parents and an information sheet filled by interview with them concerning general health, feeding habits and frequency of oral infections (tonsillitis and oral thrush) of their children. Exclusion criteria were antibiotic and or antimycotic treatment in the previous three months at least and the presence of chronic disease, then the children were examined clinically using WHO criteria and the index recorded as dmft (21). Microbiological samples were obtained from children by swapping their mucosal surface of the cheek, hard palate, dorsum of the tongue and floor of the mouth with sterile cotton swap (22) .All these swaps cultured aerobically. Each swap streaked on blood agar, MacConkey agar, chocolate agar and sabauraud,s dextrose agar then incubated aerobically for 24 hours at 370 C(23) . The morphology of different types of colonies was recorded and smears of these different colonies were done to study the Gram's reaction and microscopical characteristic (24). Different types of colonies were sub cultured and stored for further biochemical tests to reach complete identification of each isolate. These tests include: 1. Hemolysis on blood and choclate agar plates (25) . 2. Differential and selective culture media: MacConkey's agar to observe lactose and non lactose fermenter colonies (Oxoid, England), Sabauraud's dextrose agar (Difco, USA) and Mannitol salt agar to observe mannitol fermenter colonies (Difco, USA). 3. Catalase test(24). 4. Oxidase test. 5. Slide Coagulase test(26). 6. Imvic(24) 7. Urease test (24) . 8. Kliger iron agar (KIA) test (27). 9. Bacitracin differentiation test (28). 10. Optochin sensitivity test (27).

RESULTS
Children affected by tonsillitis continuously were more among caries active children (75%), while those affected by tonsillitis occasionally were (68.75%) caries free. There was no association between caries activity and frequency of tonsillitis. Concerning candidal infection, children affected continuously were more among caries active children 77.78%, while those affected few and distant times with candidiasis were more among caries free children 70.83% (Table 1). Significant association was found between caries activity and frequency of candidal infections (X2=9.217, P<0.01). There are 13 different types of microorganisms among caries active children, while in those with caries free children there were only 10 different types of microorganisms (Table 2). In caries active children, the highest percentage was appeared to be found for Strept.viridans, Moraxella, Candida, Strep. Pyogenes ( 100%, 95.45%, 86.36% and 72.73% respectively), however, in caries free children the highest percentage was appeared to be found for Strept.viridans and Moraxella, followed by Staph. Epidermidis and then Candida. Highly significant association was found between caries activity and types of microorganisms (X2=33.364, P<0.01). A comparison between caries active and caries free children by method of feeding was shown in Table 3, it was found that most of caries active children were fed by bottle feeding method (72.73%), while those with caries free were fed by breast feeding method(72.73%). Statistically, there was an association between caries activity and method of feeding. Table(4) reveals that only (8.33%) breast fed children and (83.33%) bottle fed children were affected continuously by tonsillitis; continuous infection was more among bottle fed children than breast fed children. On the other hand, all those with continuous candidal infections were feeding by bottle feeding method, while neither the breast nor the mixed fed children were affected continuously by candidiasis. Highly significant association was found between feeding method and frequency of infections regarding tonsillitis and candidiasis (P<0.01).

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DISCUSSION
Although oral infections are usually not life threatening, it should be remembered that oral health is one of the most important part of the general body health. It is well documented that dental caries is the most prevalent oral disease among children and young adults(29) and also it is considered as a public health problem(30). According to some studies(31,32,33) the immune system of the oral cavity and the regulation the oral microflora is considered as very important in caries pathogenesis and that formation of immune system of the oral cavity to a great extent depend on the regional lymphoid organs and main role belongs to laryngeal and pharyngeal tonsils, (Tonsils are considered as lymphoid organs, providing oral cavity by immunoglobulins in cooperation with salivary glands, consequently it is supposed that tonsils play an essential role in suppression of cariogenic microflora, thereby providing caries prophylaxis or vice versa) (34). The percentage of caries active children affected by tonsillitis and candidiasis continuously was higher than that of caries free children and this could be due to the significant changes in the oral ecosystem that was detected between the caries active and caries free children that may attributed to the difference between the two groups. Present microbial investigations has shown that the predominant bacterial isolates which had been found in both caries active and caries free children were Strep.viridans and Moraxella. These two microorganisms are normal flora in the mouth and the presence of Moraxella in this high percentage is in agreement with other studies (16,35) . The correlation between high prevalence of candidal species in dental plaque and saliva and the development of active caries lesions is supported by many studies( 34,36,37,38) ,as well as the present study that showed the next most common microbial isolates among caries active children was Candida (86.36%) compared to (9.09%) in caries free children and this can explain the higher frequency of continuous candidal infections among caries active children. Strep.pyogenes is a -haemolytic, it is one of the commonest bacterial pathogens that cause pharyngotonsilitis all over the world (39). In the present study, Strep.pyogenes

found in less frequency in caries free children which is in agreement with Nolte(35) who reported that these microorganisms are not commonly found in the oral cavity. On the other hand, Sterp. pyogenes isolates represents (72.73%) in caries active children, this higher percentage may be due to a positive correlation which was found between the presence of Strep.pyogenes in oral cavity of children and dental caries (35), and this is true concerning the present study and this higher percentage can support the higher frequency of continuous tonsillitis among caries active children, this was in agreement with Kipiani study (33) . In the present study, caries active children were mostly fed by bottle feeding method, however, breast feeding was the predominant feeding method among caries free children and this was similar to previous studies (3,15-18) this could be due to the fact that human breast milk have buffer capacity that eventually able to prevent caries (3,9) and it contains caries protective elements such as maternal immunoglobulins, enzymes, leucocytes and specific antibacterial agents (40-42) , in addition to that cariogenic bacteria may not be able to utilize lactose as an energy source as readily as sucrose (43) and Streptococcus mutans is highly susceptible to the bactericidal action of lactoferrin (which is found in the breast milk) that chelates iron, making this essential nutrient inaccessible to an invading microorganisms (44). So as a conclusion, oral infections (tonsillitis and candidiasis) are frequently occur among children with dental caries, therefore, health education for parents and children to improve their knowledge concerning the effects of dental caries and oral infections should be planned and carried out skillfully throughout specified community health programs. Young nursing mothers should be advised and encouraged about the beneficial effects of breast feeding for the childs health since that it contains a lot of high quality nutrition to enhance the immune system, also contains other elements that have protective effects against caries process, while bottle feeding contain very high sugar and low on other nutrition elements, if it is delivered in a wrong way it can caused caries.

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Table 1: Frequency of oral infection occurrence among caries active and caries free children
Variables Tonsillitis Candidal infection Frequency of infection Continuously Occasionally Few and distant times Continuously Occasionally Few and distant times Caries active 9(75.00%) 5(31.25%) 8(50.00%) 7(77.78%) 8(72.73%) 7(29.16%) Caries free 3(25.00%) 11(68.75%) 8(50%) 2(22.22%) 3(27.27%) 17(70.83%) Total 12 16 16 9 11 24 X2 N.S.

9.217 *

*Highly significant, P<0.01, df = 2

Table 2: Distribution of caries active and caries free children according to the types of microorganisms
Type of micro-organisms Strep.viridans Strep.faecalis Strep.pyogen Strep.pneumonia Moraxella Candida Staph.aureus Staph.epi. E.coli Acinetobacter Enterobacter Pseudomonas Klebsiella Caries active 22 14 16 1 21 19 6 15 6 5 3 1 1 Caries free 22 1 1 0 22 2 1 7 1 2 0 0 1 X2

33.364*

*Highly significant, P<0.01, df=12

Table 3: Distribution of caries active and caries free children according to methods of feeding
Feeding method Breast feeding Bottle feeding Mixed feeding Total Caries active 1 (4.55%) 16(72.73%) 5(22.73%) 22 Caries free 16(72.73%) 2 (9.09%) 4(18.18%) 22 X2 24.235*

*Highly significant, P < 0.01, df= 2

Table 4: Occurrence of oral infections by method of feeding


Variables Tonsillitis Candidal infection Frequency of infection Continuously Occasionally Few and distant times Continuously Occasionally Few and distant times Breast feeding 1(8.33%) 9(56.25%) 7(43.75%) 0(0.00%) 4(36.36%) 13(54.17%) Bottle feeding 10(83.33%) 2(12.50%) 6(37.50%) 9(100.00%) 6(54.54%) 3(12.50%) Mixed feeding 1(8.33%) 5(31.25%) 3(18.75%) 0(0.00%) 1(9.09%) 8(33.33%) Total 12 16 16 9 11 24 X2 14.523*

22.388*

*Highly significant, P < 0.01,df = 4

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25. Mellevilli TH, Russel CL. Microbiology for dental students. 3rd ed. CV Mosby Co.; 1981. p. 299-373. 26. Marmins, Swain. Cite in medical microbiology, 12th ed. CV. Mosby Co., USA; 1973. p.120-129. 27. Steve K, Alexander and Dennis S. Microbiology. A photographic atlas for the laboratory. 2001:69-92. 28. Barbara SR, Gail LW. Medical bacteriology. In Henry JB (ed). Clinical diagnosis and management by laboratory methods. 20th ed. London: W.B. Saunders Co.; 2001.Vol.3. p. 1093-1096. 29. Murry J. The prevention of oral disease. 3rd ed. Oxford: Oxford University Press; 1995. 30. Annerosa B,Maik W, Susanne K. Early Childhood Caries: A multi-factorial disease. OHDMBSC, 2010; IX (1):32-38. 31. Abico Y. Passive immunization against dental caries diseases, development of recombinant and human monoclonal antibodies. Critical Reviews in oral biology and Medicine 2000; 11(2):140-158. 32. Childers NK, Tong GL, Dasanayke AP, Kink K, Michalek SM. Human immunized with Streptococcus mutans antigens by mucosal routes. J Dent Res 2002; 81(1):48-50. 33. Kipiani G, Davladze K. Dental caries in children with chronic tonsillitis. Annals of Biomedical Research and Education.2003; 3(2):86-90. 34. Marchant S, Brailsford SR, Twomey AC, Roberts GJ, Beighton D. The predominant microflora of nursing caries lesions. Caries Res. 2001; 35: 397-406. 35. Nolte WA. Oral microbiology with basic microbiology and immunology. 4th ed. CV Mosby Co.; 1982. p.424, 362,413. 36. Nikawa H, Yamashiro H, Makihira S. In vitro cariogenic potential of Candida albicans. Mycoses 2003; 46:471-478. 37. Ersin NK, Eronat N, Cogulu D, Uzel A, Aksit S. Association of maternal- child characteristics as a factor in early childhood caries and salivary bacterial counts. J Dent Child (Chic) 2006; 73:105-111. 38. Moalik E, Gestalin A, Quinio D, Gest PE, Zerilli A, Le Flohie AM. The extent of oral fungal flora in 353 students and possible relationship with dental caries. Caries Res 2001; 35:149-155. 39. Abdullah MA. Group A streptococcal tonsillar infection among primary school children in Sammarra. M.Sc. thesis, University of Tikrit, 2003. 40. Hallett KB, ORourke PK. Social and behavioral determinant of early childhood caries. Australian Dent J. 2003;48:(1): 27-33. 41. Roberts GJ, Cleaton- Jones PE, Fatti LP. Pattern of breast and bottle feeding and their association with dental caries in 1-to-4-year-old South African children. Comm Dent Health 1993; 10:405-413. 42. Oddy WH, Peat JK. Breast feeding, asthma and atopic disease: an epidemiological review of the literature. J Hum Lact 2003; 19: 250-61. 43. Arnold R. Bactericidal effect of human lactoferrin. Science 1977; 197(4300): 263-5. 44. Rugg- Gunn. Effect of human milk on plaque pH in situ and animal dissolution in vitro compared with bovine milk, lactose and sucrose. Caries Res 1985; 19: 327-34.

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The staining effect of chlorhexidine mouthwash on non metallic brackets (An in vitro comparative study)
Hayder J. Attar, B.D.S., M.Sc. Fakhri A. Ali, B.D.S., M.Sc. (2)
(1)

ABSTRACT
Background: Since it is needed to have means other than mechanical plaque control to achieve good oral hygiene in orthodontic patients, and since an eliminating the metallic appearance of orthodontic appliance is always desired to achieve a maximum esthetic appliance, so this study was done to investigate and compare the staining effects of chlorhexidine mouthwash 0.2% on the un bonded ceramic brackets, ceramic brackets bonded with no mix adhesive, ceramic brackets bonded with light cured adhesive, un bonded composite brackets, composite brackets bonded with no mix adhesive and composite brackets bonded with light cured adhesive. Materials and Methods: The effect of the chlorhexidine was studied through immersion the brackets and bonded brackets in the mouth wash for three different time intervals: 1, 2 and 3 hours, which represent the accumulated daily use of the mouthwash for 1, 2, and 3 months respectively and compared them with corresponding control groups which not immersed in chlorhexidine 0.2%. The sample consisted of two hundred eighty eight brackets. AShimadzu, UV 160A UV-Visible spectrophotometer was used to perform a light absorption test for each subgroup with twelve brackets each. Results: ANOVA and LSD post Hoc tests were used to identify the significant effects of the mouthwash at a significance level P 0.05, A significant effects identified with ceramic brackets bonded with no mix adhesive, ceramic brackets bonded with light cured adhesive, un bonded composite brackets, composite brackets bonded with no mix adhesive and composite brackets bonded with light cured adhesive, while non significant effect of un bonded ceramic brackets. Conclusions: It can be concluded that the chlorhexidine mouthwash do not have a staining effect on the un bonded ceramic brackets while significant changes in staining effect when ceramic and composite brackets bonded to no mix adhesives and that effect decrease when bonded to light cured adhesives. The mouthwash has a staining effect on the un bonded composite brackets also. Key words: Ceramic bracket, composite bracket, chlorhexidine. (J Bagh Coll Dentistry 2012;24(2):109-113).

INTRODUCTION
The esthetic requirements of orthodontic treatment prompted the development of toothcolored brackets as alternatives to metal brackets (1) . Many types of nonmetallic brackets fabricated from alumina and zirconia ceramics, as well as a variety of plastic brackets and composite brackets had been introduced during the past decades (2) Some of the earliest applications of chlorhexidine for the control of plaque and gingivitis go back to 1970s, when the dental literature reported on the use of 0.2% chlorhexidine gluconate rinses; twice a day; to prevent plaque accumulation and subsequent gingivitis (3). The adequate plaque control was difficult in patients undergoing orthodontic treatment, especially in the cases of children and adolescents and when bands and auxiliaries were involved (4). Many researchers classified staining as either extrinsic or intrinsic (5, 6) .There was confusion concerning the exact definitions of these terms. Feinman et al (7) described extrinsic discoloration as occurring when an agent stains or damage the enamel surface of teeth and intrinsic staining as occurring
(1)M.Sc. student, Department of Orthodontics, College of Dentistry, University of Baghdad. (2)Professor, Department of Orthodontics, College of Dentistry, University of Baghdad

when internal structure is penetrated by a discoloring agent; according to his definition; the term staining and discoloration were used synonymously. However; extrinsic staining defined as staining that could be easily removed by normal prophylactic cleaning, intrinsic staining was defined as endogenous discoloration that had been incorporated in to the structure matrix and thus could not be removed by prophylaxis (8). The etiology of the dental discoloration is multifactorial in which different part of the tooth could take up different stains (9). Mouth wash containing chlorhexidine caused superficial black and brown staining of the teeth (10, 11) . Ceramic brackets are more esthetic than metal brackets, and unlike plastic or composite brackets, they resisted staining and discoloration
(12)

Orthodontic adhesives could have intrinsic and extrinsic discoloration, chlorhexidine could discolor composite extrinsically and with time become intrinsically throughout a resin matrix, which was usually attributable to chemical degeneration of the fillerresin bond and solubility of the resin matrix (13).

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MATERIALS AND METHOD


Two types of brackets were used in this study, they were of standard edgewise (2230 slot dimension), and with horizontal grooves in the base of bracket to generate a macro-retention undercuts to achieve maximum mechanical bonding surface. They include: Reflections ceramic brackets which was made from 99.9% pure polycrystalline alumina, Rave composite brackets were made from Injection Molded High Quality Reinforced Composite to increase bracket body strength with precise slot dimensions(Ortho Technology/U.S.A.( Resilience No-Mix orthodontic adhesive, Resilience Primer, Resilience Light-Cure orthodontic adhesive, Resilience light cure Primer(OrthoTechnology/U.S.A.) were used for bonding . Corsodyl Chlorhexidine digluconate 0.2% W\V, (GlaxoSmithKline, UK) was used as a test immersion media in the study. Bonding procedure: The sample composed of 144 Reflections ceramic brackets and 144 Rave composite brackets, the brackets were divided according to bond material into three groups of 48 brackets: Un bonded brackets which were not bonded to any bond materials. Chemically cured bonded brackets in which the brackets were bonded using chemically cured adhesive resin. Light cured bonded brackets in which the brackets were bonded using light cured adhesive resin. The ceramic and composite brackets were bonded with a chemically cured, light-cured orthodontic adhesive as follow: Resilience Primer was applied by brush on each bracket base or Resilience light cure Primer used with Resilience Light-Cure orthodontic adhesive . A small amount of the adhesive paste was applied onto the bracket base, and then by using a clamping tweezer the bracket was placed lightly onto a horizontal flat plastic plate mounted on the table of surveyor(Dent aurum, Germany) covered by a celluloid strip to facilitate detachment of the bracket adhesive complex with a recovery of the set material. A constant load of two hundred grams was placed on the bracket to ensure a uniform thickness of the adhesive, the load fixed to the upper part of the vertical arm of the surveyor, a surveyor rod was fixed in the lower part of the vertical arm of the surveyor and put it in contact with the bonded bracket, excess
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adhesive was removed from around the bracket base with a sharp scalar (Bishara et al, 2005) The visible light-cured adhesive specimens were photopolymerized with a light-curing unit (YDL/ Hangzhou Yinya Co.,China); the light guide of curing light unit was directed toward the bracket, the light shined through the bracket for 20 second (according to manufacturer instruction .(The bonded brackets were allowed to bench set for 24 hr to ensure complete polymerization of adhesive material, then after setting; the celluloid strips were removed and the resultant bracketbonded adhesive were flat. Immersion in chlorhexidine: Un bonded and bonded brackets were farther subdivided according to time interval immersion in chlorhexidine 0.2% into four groups with 12 brackets each which include 1 hour,2 hours ,3 hours immersion in chlorhexidine and one control group which not immersed in chlorhexidine. Then the immersion procedure was done by positioned each bracket on a black rectangular cardboard (35450.2 mm) with central window, the cardboards were numbered and using the number of the card as a reference .The specimens then immersed in Chlorhexidine 0.2% solution contained in inert plastic containers. Immersion was done according to the different time intervals for one, two, and three hours in Chlorhexidine gluconate mouth rinse 0.2% at 37 in the incubator Assessment of staining : The samples were taken out of the immersion media; then Staining measurements were performed over the 800 to 200 m visible wavelength range with UV-Visible spectrophotometer (Shimadzu; UV160A; Japan.( The chamber of the spectrophotometer was opened, and then the black rectangular cardboard with bracket positioned in central window was used to position the bracket in the front part of the analytical beam holder of spectrophotometer, Then the chamber was closed and the machine was given the order to start scanning starting from 800m wavelength in the infra-red zone to 200m wavelength in the UV zone passing through the entire visible spectrum . The light passes through the sample; then the intensity of the remaining light was measured with a light sensor, the results appeared as a graph from which the amount of light absorption was plotted and the amount of absorbed light at a 345m wavelength visible light was obtained and used in the later statistical analysis .

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Statistical analysis Descriptive statistics: including mean, standard deviation, and standard error. Inferential statistics: including: One way analysis of variance (ANOVA) to test any statistically significant difference among the light absorption of groups and Least significant difference (LSD)to test any statistically significant differences between each two subgroups when ANOVA showed a statistical significant difference within the same group. Significance for all statistical tests was predetermined at P .05.

RESULTS
The staining effect of chlorhexidine 0.2%Effect of time: Generally, for most groups the amount of light absorption increase as time of immersion in the chlorhexidine increase. But, in un bonded ceramic brackets group the readings of light absorption in control and after 1, 2 and 3 immersion hours in the chlorhexidine 0.2% was not changed, the peak reading in the immersion 3hours reading. Ceramic bracket group (Table 1 and Fig. 1) The Un bonded Ceramic bracket group showed a statistical non-significant difference among reading of control, 1, 2 and 3 immersion hours in Chlorhexidine 0.2% by ANOVA test . The ceramic bracket bonded with chemically cured orthodontic adhesive group (No mix) and The ceramic bracket bonded with light cured orthodontic adhesive group showed statistical significant difference among readings of control,1, 2 and 3 immersion hours in chlorhexidine 0.2% by ANOVA test. LSD test for the ceramic bracket bonded with chemically cured orthodontic adhesive group (No mix) revealed a statistical significant difference when comparing the control vs. 1 hours; a high significant difference when comparing the control vs. 2 hours and control vs. 3 hours; non significant difference when comparing 1 hour vs. 2hours; while a high significant difference when comparing 1 hour vs. 3 hours and 2 hours vs. 3 hours . LSD test for the ceramic bracket bonded with light cured orthodontic adhesive group revealed a non significant difference when comparing control vs. 1hours; a significant difference when comparing control vs. 2hours, and control vs. 3hours, a highly significant difference in LSD test when comparing 1 hour vs. 2 hours, 1 hour vs. 3 hours and 2 hours vs. 3 hours. Composite bracket group (Table 1, Fig. 1) One way ANOVA test showed a statistical significant difference among reading of control, 1, 2 and 3 immersion hours in chlorhexidine 0.2% for the Un bonded composite bracket group, the
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composite bracket bonded with chemically cured orthodontic adhesive (No mix) group and the composite bracket bonded with light cured orthodontic adhesive group LSD test for the Un bonded composite bracket group revealed a statistical significant difference between the control and 1 immersion hours, control and 2 immersion hours, control vs. 3 immersion hours and when comparing 1 hour vs. 2hours and comparing 1 hour vs. 3 hours; while a non significant difference when comparing 2 hours vs. 3 hours. LSD test for the composite bracket bonded with chemically cured orthodontic adhesive (No mix) group revealed a statistical significant difference for all pair comparisons. LSD test for the composite bracket bonded with light cured orthodontic adhesive group revealed a statistical significant difference between the control and 1 immersion hours, control and 2 immersion hours, control vs. 3 immersion hours, and when comparing 1 hour vs. 2hours and comparing 1 hour vs. 3 hours; while a non significant difference when comparing 2 hours vs. 3 hours. The staining effect of chlorhexidine 0.2%Effect of adhesives: For both the ceramic and composite bracket groups; the peak light absorption appear in brackets bonded with no mix then the readings decreased in brackets bonded with light cure and the least reading of light absorption was in Un bonded brackets for the same time interval in control, 1, 2 and 3 hours of immersion in the chlorhexidine 0.2% . When comparing the amount of light absorption by ceramic and composite brackets bonded with different adhesives at the same time interval by ANOVA test a statistical significant difference was found (p<0.001) among brackets bonded with no mix, brackets bonded with light cure and Un bonded brackets. LSD test appeared that a significant difference found when comparing Un bonded brackets vs. brackets bonded with no mix, un bonded brackets vs. brackets bonded with light cure and when comparing brackets bonded with no mix vs. brackets bonded with light cure.

DISCUSSION
The Un bonded Ceramic brackets was made from Aluminum oxide which is an inert material due to the crystalline structure of ceramic; as a result, it cannot chemically interact to any of the chlorhexidine molecules; also the glazed surface of the bracket reduce the overall surface roughness and the adsorption of chlorhexidine on bracket surface. (Table 1, Fig. 1)

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

REFEERENCES
1. Swartz ML. Ceramic brackets. J Glin Orthod 1988;22: 82-88. 2. Eliades Theodore, George Eliades, Brantley, and Johnston: Orthodontic Materials: scientific and clinical aspects.2nd ed.: Thieme, Stuttgart, Germany 2001.P.557-647, 77-82.

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3. Le H., Schitt CR, Glavind L., Karring T. Two years oral use of chlorhexidine in man. J Periodont Res 1976; 11:135-44. 4. Lundstrm F, Hampton SE. Effect of oral hygiene education on children with and without subsequent orthodontic treatment. Scand J Dent Res 1980;88:539. 5. Dayan D, Hiefferman A, Goreski M,Beigleiter A. Tooth discoloration-extrinsic and intrinsic factors. Quintessence Int 12(14)1983: 1-5. 6. Hayas PA, Full C, Pingham J. The etiology andtreatment of intrinsic discolorations. J Clin Dent Asso1986: 217-20. 7. Feinman RA,Goldstein RE, Garber DA. Bleaching teeth.1st ed.Quintessence:1987:188-195. 8. Teo CS. Management of tooth discolorations. Acta Med Singapore; 1989. p 585-90.

9. Eriksen HM, Nordbo H, Kantanin H. Chemical plaque control and extrinsic tooth discoloration, A review of possible mechanisims. J Clin Periodont 1985; 12: 24550. 10. Leard A, Addy M. The propensity of different brands of tea and cafee to cause staining associated with chlorhexidine. J Clin Period 1997; 24:115-118 11. Eley BM,Antibacterial agents in the control of supragingival plaque. Br Dent J 1999;186:286-96. 12. Meguro D, Hayakawa T, Kawasaki M, Kasai K. Shear bond strength of calcium phosphate ceramic brackets to humen enamel. Angle Orthod 2006; 76(2): 301-5 . 13. Matasa CG. Resin-based composites. Today For half a century, little progress: however, nanos are behind the corner! The orthodontic materials insider 2005; 17(3).

Table 1: Descriptive statistics of the amount of light absorption by different bracket groups at different time interval of immersion in chlorhexidine 0.2%
Brackets Time control 1 HR 2 HR 3 HR control 1 HR 2 HR 3 HR N 12 12 12 12 12 12 12 12 Un bonded Brackets Mean SD SE 2.072 0.007 0.002 2.072 0.007 0.002 2.072 0.007 0.002 2.073 0.007 0.002 2.042 0.002 0.000 2.131 0.005 0.001 2.254 0.005 0.001 2.256 0.008 0.002 Bracket +no mix Mean SD SE 2.315 0.005 0.001 2.325 0.010 0.003 2.332 0.020 0.005 2.350 0.005 0.001 2.261 0.004 0.010 2.355 0.011 0.003 2.428 0.006 0.001 2.447 0.005 0.001 Bracket +Light cure Mean SD SE 2.224 0.008 0.002 2.232 0.005 0.001 2.252 0.020 0.005 2.274 0.010 0.003 2.245 0.014 0.004 2.280 0.005 0.001 2.347 0.008 0.002 2.348 0.004 0.001

Ceramic

Composite

Figure 1: the amount of light absorption of ceramic and composite bracket groups at different time interval of immersion in chlorhexidine 0.2%

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Tooth attrition patterns

Tooth attrition patterns in a group of Iraqi adults sample with different classes of malocclusion (A comparative study)
Issam M. Abdullah, B.D.S. (1) Ausama A. Al- Mulla, B.D.S., Dr.D.Sc. (2)

ABSTRACT
Background: Tooth attrition is wearing away of tooth structure during mastication. This study investigated tooth wear patterns in adults with different classes of malocclusion and compared them with normal occlusion. Materials and methods: The sample consisted of 363 subjects that were divided into 5 groups with an age range 1825 years: 85 normal occlusion, 128 class I with crowding, 90 class II division 1, 30 class II division 2 and 30 class III. Dental wear was assessed by using a modified version of the tooth wear index. Results: 1. The class I malocclusion group had statistically greater tooth wear in incisal surfaces of maxillary central and lateral incisors, and mandibular lateral incisors than did the normal occlusion. 2. The class II division 1 group had statistically greater tooth wear in the occlusal surfaces of maxillary second premolars, mandibular first and second premolars. Buccal surfaces of mandibular canines, mandibular second premolars and mandibular first molars than did the normal occlusion. 3. The class II division 2 malocclusion group had statistically greater tooth wear in labial surfaces of mandibular central and lateral incisors. Buccal surfaces of mandibular second premolars, mandibular first molars. Occlusal surfaces of maxillary first and second premolars and mandibular second premolars than did normal occlusion. 4. The class III malocclusion group had statistically greater tooth wear in the occlusal surfaces of maxillary first and second premolars than did normal occlusion. Conclusion: In conclusion subjects with normal occlusion and those with different classes of malocclusions have different tooth wear patterns. Keywords: attrition, wear patterns, modified tooth wear index. (J Bagh Coll Dentistry 2012;24(2):114-119).

INTRODUCTION
Due to the decreasing occurrence of dental caries in many societies, increasing attention has focused on tooth wear from erosion, abrasion and attrition (1). Tooth wear is a normal physiologic process that occurs through a variety of mechanisms and increases with age. It can be defined as the noncarious loss of tooth substance as a result of the combined processes of erosion, attrition, and abrasion; these terms reflect specific etiologic factors (2). Gradual attrition of the occlusal surfaces of the teeth appears to be a general physiologic phenomenon in all mammals, in every civilization, and at all ages. Tooth wear has characteristic features that must be distinguished from abrasion and erosion and characterized as flat, sharply or round angled and polished surfaces and may come from excessive attrition of one tooth against the other (3) .Smith and Knight (4) introduced the tooth wear index (TWI), which attempted to provide a solution to some problems associated with measuring wear at the individual and community levels. The TWI and modified versions of it have been used in many studies; this suggests widespread acceptance (5-7). However, it was described as flawed when used in an aging population, because
(1) MSc. Student, Department of Orthodontics, College of Dentistry, Baghdad University. (2) Professor, Department of Orthodontics, College of Dentistry, Baghdad University.

it does not take into account teeth that were restored due to wear (8). The modifications matched the World Health Organization standards, thus allowing application of the index in broad epidemiologic surveys for both of deciduous and permanent dentitions (9). Some studies indicate that masticatory forces and malocclusion are primary etiologic factors for noncarious lesion development (10-14), although other authors did not find this correlation (15-18). Because of the high prevalence of malocclusions as well as the controversies in the studies of tooth wear, it is relevant to verify the pattern of tooth wear of various occlusal relationships to help professionals to differentiate between physiologic and pathologic processes.

MATERIALS AND METHODS


The sample has been selected randomly from the students of Babylon university (college of medicine, college of dentistry and college of nursing) and some patients were selected randomly from the patients attended the orthodontic department and oral medicine department of dentistry college of Babylon University. Out of 440 persons only 363 subjects were selected (18-25 years old) and divided into five groups: 1. Group one included 85 subjects with normal occlusion (45 males and 40 females).

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2. Group two included 128 subjects with class I malocclusion with crowding (63 males and 65 females). 3. Group three included 90 subjects with class II division 1 malocclusion (35 males and 55 females). 4. Group four included 30 subjects with class II division 2 malocclusion (12 males and 18 females). 5. Croup five included 30 subjects with class III malocclusion (14 males and 16 females). The sample was taken in terms of the following criteria:1. The sample was all of Iraqi Arab in origin. 2. No previous orthodontic treatment. 3. No extracted teeth up to the first molar. 4. No openbite. 5. No parafunctional habits. 6. No temporomandibular joint problems. The surfaces of all teeth in the mouth were scored according to tooth wear index by Smith and Knight (4) modified by Sales Peres et al.(7). The modifications matched the World Health Organization standards (9), thus allowing application of the index in broad epidemiologic surveys for both of deciduous and permanent dentitions. The modifications made calibration easier because the modified tooth wear index does not differentiate the depth of dentin involvement, as does the original tooth wear index. In addition, the modified version includes a code for teeth that have been restored due to wear (code 4) and another code for teeth that cannot be assessed (code 9); the amount of permanent tooth wear is scored by numbers (Table 1). Each 2 groups were compared using Mann Whitney test for the frequency and severity of wear on each surface of each group of teeth.

RESULTS
In total, 17424 dental surfaces were evaluated. Of these, 64.2 % had no dental wear (score 0), 33.8% had incipient lesions (score 1), 1.3 % had moderate lesions (score 2) and 0.7% were excluded (score 9).No severe lesions were found. 1. Class I (crowding): The class I malocclusion group had statistically greater tooth wear in incisal surfaces of maxillary central incisors, incisal surfaces of maxillary lateral Incisors and incisal surfaces of mandibular lateral incisors ( table 2) than did the normal occlusion. The normal occlusion group had statistically greater tooth wear in the incisal surfaces of maxillary canines and Buccal surfaces of mandibular first (tables 2), than did the class I malocclusion (crowding).
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2. Class II division 1: The normal occlusion group had statistically greater tooth wear in the incisal surface of maxillary lateral incisors incisal surface of mandibular central incisors and incisal surface of maxillary canine than did the class II division 1 malocclusion group, (table 3). The class II division 1 group had statically greater tooth wear in the occlusal surfaces of maxillary second premolars, occlusal surfaces of mandibular first premolars , occlusal surfaces of mandibular second premolars (table 3), labial surfaces of mandibular canines, buccal surfaces of mandibular second premolars and buccal surfaces of mandibular first molars than did the normal occlusion group, (table 3) 3. Class II division 2: The normal occlusion group had statistically greater tooth wear in the incisal surface of maxillary lateral and incisal surfaces of maxillary canines than did class II division 2 group, (table 4). The class II division 2 malocclusion group had statically greater tooth wear in labial surfaces of mandibular central incisors, labial surfaces of mandibular lateral incisors, buccal surfaces of mandibular second premolars, buccal surfaces of mandibular first molars, occlusal surfaces of maxillary first premolars, occlusal surface of maxillary second premolars, and occlusal surfaces of mandibular second premolars than did normal occlusion group, (table 4). 4. Class III: The normal occlusion group had statistically greater tooth wear in the incisal surface of maxillary central incisors, incisal surface of maxillary lateral incisors, incisal surface of maxillary canines, incisal surfaces of mandibular central incisors, incisal surfaces of mandibular lateral incisors, incisal surfaces of mandibular canines, palatal surfaces of maxillary central incisors, palatal surface of maxillary lateral incisor, palatal surface of maxillary canines, occlusal surfaces of mandibular first molars and buccal surfaces of mandibular first molars than did class III group, (tables 5). The class III malocclusion group had statistically greater tooth wear in the occlusal surfaces of maxillary first premolars and surfaces of maxillary second premolars than did normal occlusion group, table (table 5).

DISCUSSION
The results of this study showed that the normal occlusion patients and those with class I malocclusion (crowding), class II division 1, class II division 2 and class III had some tooth wear.

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However, the groups had different tooth wear patterns, Tables (2-5). 1. Class I malocclusion (crowding) The normal occlusion group differs from class I with crowding in that the normal occlusion tooth wear was greater on the incisal surfaces of the maxillary canines, compared with the corresponding surfaces of the malocclusion group(table 2), this probably occurred because of the normal anteroposterior relationship, establishing immediate lateral guidance during lateral mandibular excursions (19). Since these teeth disclude the posterior teeth during lateral mandibular functional movements, it seems logical that they have greater wear, this finding came to be in agreement with Janson et al.2010 (23) and Oltramari et al. 2010 (24). As a result of unfavorable positioning of the canines in class I crowding as in many cases of class I coming with buccally malposed canines these teeth also do not disclude the posterior teeth as frequently as in normal occlusion, because of interferences of the posterior teeth (19, 25). Thus, there is less wear on the incisal surfaces of the maxillary canines in the class I group. Thus, there is less wear on the incisal surfaces of the maxillary canines in the class I group. The buccal surfaces of mandibular first molars had tooth wear more than the class I malocclusion (crowding), this may be due to the subjects with crowding had narrower arches than the normal occlusion (20, 21) so the maxillary first molars did not probably overlap the mandibular molars. Thus, there is less wear in the buccal surface of mandibular first molar because all of the wear located in areas of occlusal contact (22). The more tooth wear in incisal surfaces of maxillary and mandibular incisors in class I crowding subjects may be due to irregularities and disarrangement of these teeth, table. 2. Class II division 1 malocclusion In the normal occlusion group, tooth wear was greater on the incisal surfaces of the maxillary lateral incisors and canines and mandibular central incisors compared with the II division 1 malocclusion (table 3). Greater tooth wear in the anterior region in the normal occlusion group probably occurred because of normal vertical and horizontal anterior tooth relationships, establishing immediate anterior and lateral guidance during protrusion and lateral mandibular excursions, respectively (19, 25). As we mentioned above these teeth disclude the posterior teeth during mandibular functional movements, so it will have greater wear, this finding came to be in agreement Janson et al. (23) and partial agreement

with Oltramari et al. (24) and this may be due to size and age of sample. Class II Division 1 malocclusion group showed greater tooth wear on the posterior teeth (table 3), this may be due to two factors. One is the large overjet that increases the likelihood of interferences of the posterior teeth during protrusion until the incisors make contact as the mandible is advanced (19, 25). The other is that, because the canines are not in a favorable position to disclude the posterior teeth, these take the role of the canines during lateral mandibular excursions and are therefore subjected to greater wear. 3. Class II division 2 malocclusion In the normal occlusion group, tooth wear was greater on the incisal surfaces of the maxillary lateral incisors and the maxillary canines, compared with the corresponding surfaces of class II division 2 malocclusion group (table 4). Less wear on the incisal surfaces of the maxillary lateral incisors in the Class II malocclusion group presumably is a consequence of the labial positioning of these teeth in this type of malocclusion, which also is characterized by uprighted central incisors, deep overbite, and normal overjet (26-29) .With this interocclusal arrangement, disclusion on protrusion is carried out primarily by the maxillary central incisors with occasional contact of the lateral incisors. Greater tooth wear on the incisal surfaces of the canines in the normal occlusion group, probably occurred because of the normal anteroposterior relationship, establishing immediate lateral guidance during lateral mandibular excursions (19, 25) . In comparison with normal occlusion, subjects with class II division 2 had greater wear on the labial surfaces of mandibular incisors and this may be due to this type of malocclusion characterized by uprighted central incisors, deep overbite, and normal overjet (26-29) , thus during protrusion subjected to greater tooth wear. Subjects with Class II Division 2 malocclusion had greater wear on the posterior teeth (occlusal surface of maxillary first and second premolars and mandibular second premolar and buccal surfaces of maxillary second premolar and first molar), a difference that was statistically significant compared with that of the normal occlusion sample, and this may be because the canines are not in a favorable position to disocclude the posterior teeth during lateral excursions in class II division 2 malocclusion, the posterior teeth assume this role and consequently have greater wear than observed in the normal occlusion group. This occlusal configuration occurs because of the broad, square-shaped

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maxillary arch with a relatively normal mandibular arch, characteristics of this malocclusion (26-29). These surfaces are worn during lateral movements of the mandible on the working side. 4. Class III malocclusion In the normal occlusion group, tooth wear was greater on the incisal surfaces of the anterior teeth (maxillary and mandibular), compared with the III malocclusion (table 5). Greater tooth wear in the anterior region in the normal occlusion group probably occurred because of normal vertical and horizontal anterior tooth relationships, establishing immediate anterior and lateral guidance during protrusion and lateral mandibular excursions, respectively (19, 25), in contrast to subjects with class III malocclusion have lesser tooth wear in anterior teeth and this may be due to many subjects with class III come with edge to edge or sometimes openbite and the overjet and overbite decrease (30-32) ,this seems to be the reasons for less wear in anterior teeth of class III subjects. Due to the reverse relationship in class III malocclusion, the normal occlusion group has greater wear in palatal surfaces of maxillary anterior teeth. On the other hand, subjects with normal occlusion have greater wear in buccal surfaces of mandibular first molars, and the subjects with class III malocclusion have less wear in molars which may be due to the fact that the maxillary arch widths were usually narrower than the mandibular arch widths and lingually positioned maxillary posterior teeth (posterior crossbite) are often seen in the class III malocclusion (33-34), it seems logical that they have less wear in molars. Subjects with class III have fewer teeth wear than the normal occlusion group. On the other hand, patients with Class III malocclusion had greater wear on the maxillary premolars, a difference that was statistically significant compared with that of the normal occlusion sample, and this may be because the canines are not in a favorable position to disclude the posterior teeth during lateral excursions in class III malocclusion, the premolars assume this role and consequently have greater wear than observed in the normal occlusion group.

REFERENCES
1. Vehkalaht M, Tarkkonen L, Varsio S, et al. Decrease in and polarization of dental caries occurrence among child and youth populations. Caries Res 1997; 31:1615. 2. Smith BG. Tooth wear: aetiology and diagnosis. Dent Update 1989; 16:204-12. 3. Cunha Cruz J, Pashova H, Packard JD, Zhou L, Hilton TJ for Northwest Precedent. Tooth wear: prevalence and associated factors in general practice patients. Community Dent Oral Epidemiol 2010; 38: 22834.

4. Smith BGN, Knight JK. An index for measuring the wear of teeth. Br Dent J 1984; 156: 435-8. 5. OBrien M. Childrens dental health in the United Kingdom 1993. London: HMSO; 1994. 6. Jones SG, Nunn JH. The dental health of 3-year-old children in east Cumbria 1993. Community Dent Health 1995; 12:161-6. 7. Sales Peres SHC, Goya S, de Araujo JJ, Sales-Peres A, Lauris JR, Buzalaf MA. Prevalence of dental wear among 12-year-old Brazilian adolescents using a modification of the tooth wear index. Public Health 2008; 122:942-8. 8. Donachie MA, Walls AW. The tooth wear index: a flawed epidemiological tool in an ageing population group. Community Dent Oral Epidemiol 1996; 24:152-8. 9. World Health Organization. Oral health surveys and basic methods. Geneva: World Health Unit. 1997. 10. Ritchard A, Welsh AH, Donnelly C. The association between occlusion and attrition. Aust Orthod J 1992; 12(3):138-42. 11. Henrikson T, Ekberg EC, Nilner M. Symptoms and signs of temporomandibular disorders in girls with normal occlusion and Class II malocclusion. Acta Odontol Scand 1997; 55:229-35. 12. Bryant SR. The rationale for management of morphologic variations and nonphysiologic occlusion in the young dentition. Int J Prosthodont 2003; 16:757. 13. Carlsson GE, Egermark I, Magnusson T. Predictors of bruxism, other oral parafunctions, and tooth wear over a 20-year followup period. J Orofac Pain 2003; 17:507. 14. Casanova-Rosado JF, Medina-Solis CE, VallejosSanchez AA, Casanova-Rosado AJ, Maupome G, Avila-Burgos L. Dental attrition and associated factors in adolescents 14 to 19 years of age: a pilot study. Int J Prosthodont 2005; 18:516-9. 15. Rugh JD, Barghi N, Drago CJ. Experimental occlusal discrepancies and nocturnal bruxism. J Prosthet Dent 1984; 51:548-53. 16. Seligman D.A., A.G. Pullinger', and W.K. Solberg. The Prevalence of Dental Attrition and its Association with Factors of Age, Gender, Occlusion, and TMJ Symptomatology. J Dent Res 1988; 67(10):1323-33 17. Pullinger AG, Seligman DA. Overbite and overjet characteristics of refined diagnostic groups of temporomandibular disorder patients. Am J Orthod Dentofacial Orthop 1991; 100:401-15. 18. Bernhardt O, Gesch D, Splieth C, Schwahn C, Mack F, Kocher T, et al. Risk factors for high occlusal wear scores in a population based sample: results of the study of health in Pomerania (SHIP). Int J Prosthodont 2004; 17:333-9. 19. Roth RH. Functional occlusion for the orthodontist. J Clin Orthod 1981; 15:32-40, 44-51. 20. Raymond P. Howe , James A. McNamara , Kathleen A. O'Connor. An examination of dental crowding and its relationship to tooth size and arch dimension. Am J Orthod 1983; 83 (5):363-73. 21. Timothy R. Kuntz. Robert N. Staley. Harold F. Bigelow. Charles R. Kremenak; Frank J. Kohout. Jane R. Jakobsen. Arch widths in adults with class I crowded and class III malocclusions compared with normal occlusions. Angle Orthod 2008; 78(4): 597603.

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22. Spear F. A patient with severe wear on the anterior teeth and minimal wear on the posterior teeth. J Am Dent Assoc 2008; 139:1399-403. 23. Janson G, Oltramari-Navarro P, de Oliveira R, Quaglio CL, Sales- Peres SH, Tompson B. Tooth-wear patterns in subjects with Class II Division 1 malocclusion and normal occlusion. Am J Orthod Dentofacial Orthop 2010; 137: 14.e1-14.e7. 24. Oltramari-Navarro, Janson, Salles de Oliveira. Toothwear patterns in adolescents with normal occlusion and Class II Division 2 malocclusion. Am J Ortho Dentofacial Orthop 2010; 137:730-5? 25. Roth RH, Rolfs DA. Functional occlusion for the orthodontist. Part II. J Clin Orthod 1981; 15:100-23. 26. Mills JRE. The problem of overbite in Class II division 2 malocclusion. Br J Orthod 1973; 1:34-48. 27. Ingervall B, Lennartsson B. Cranial morphology and dental arch dimensions in children with Angle Class II division 2 malocclusion. Odontol Rev 1973; 24:14960. 28. Godiawala RN, Joshi MR. A cephalometric comparison between Class II, division 2 malocclusion and normal occlusion. Angle Orthod 1974; 44:262-7.

29. Brezniak N, Arad A, Heller M, Dinbar A, Dinte A,Wasserstein A. Pathognomonic cephalometric characteristics of Angle Class II Division 2 malocclusion. Angle Orthod 2002; 72:251-7. 30. Guyer EC, Ellis EE III, McNamara JA Jr, Behrents RG. Components of class III malocclusion in juveniles and adolescents. Angle Orthod 1986; 56: 7-30. 31. Mohammed Taher Bukhary. Comparative cephalometric study of class III malocclusion in Saudi and Japanese adult females. J Oral Science 2005; 47(2):83-90 32. Namankani EA, Bukhary MT. Cephalometric craniofacial characteristics of sample Saudi female adults with class III malocclusion. Saudi Dent J 2005; 17(2): 88-100. 33. Uysal, Usumez, Memili, Sari. Dental and Alveolar Arch Widths in Normal Occlusion and Class III Malocclusion. Angle Orthod 2005; 75:80913. 34. Chen F, Terada K, Yang L, Saito I. Dental arch widths and mandibular-maxillary base widths in Class III malocclusions from ages 10 to 14. Am J Orthod Dentofacial Orthop 2008; Jan: 133(1):65-9.

Table 1: Criteria used for the measurement of tooth wear, according to the modified tooth wear index
Permanent teeth Criteria scores Normal _ no evidence of wear 0 1 2 3 4 9 Description

No loss of surface features Loss of enamel giving a smooth glazed shiny appearance, Incipient _ tooth wear into enamel dentine is not involved Extensive loss of enamel with dentine involvement. Moderate tooth wear into dentine Exposure of dentine Severe _ tooth wear into pulp or Extensive loss of enamel and dentine with secondary dentine secondary dentin. or pulp exposure Restored _tooth wear leading to The tooth received restorative treatment due to tooth wear restoration Extensive caries, large restoration, fractured tooth and Could not be assessed missing tooth,

Table 2: Intergroup tooth wear comparisons, normal occlusion and class I malocclusion (Mann-Whitney test)
tooth Class I malocclusion (crowding) Mean of scores SD Mean of scores SD Normal occlusion P

Incisal/ occlusal surface Maxillary teeth 0.729 0.521 0.867 Centrals 0.552 0.5 0.781 Laterals 0.776 0.542 0.539 Canines Mandibular teeth 0.765 0.427 0.898 Lateral /right Labial surfaces Mandibular teeth 0.2 0.402 0 First molars *Statistically significant at P < 0.05

0.341 0.01* 0.415 0.00* 0.613 0.002* 0.303 0.01*

0.001*

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Table 3: Intergroup tooth wear comparisons, normal occlusion and class II division 1(MannWhitney test)
tooth Normal occlusion Class II division 1 Mean of scores SD Mean of scores SD P Incisal/ occlusal surface Maxillary teeth 0.529 0.526 0.366 Laterals 0.776 0.542 0.533 Canines 0.176 0.383 0.288 Second premolars Mandibular teeth 0.859 0.515 0.7 Centrals 0.294 0.458 0.5 First premolars 0.129 0.337 0.411 Second premolars Palatal surfaces Maxillary teeth 0.471 0.547 0.444 Centrals Labial/ buccal surfaces Mandibular Teeth 0.071 0.258 0.167 Canines 0.047 0.213 0.177 Second premolars 0.2 0.402 0.489 First molars *Statistically significant at P < 0.05

0.484 0.04* 0.622 0.003* 0.456 0.01* 0.507 0.04* 0.503 0.006* 0.495 0.001*

0.499 0.86

0.375 0.049* 0.384 0.007* 0.489 0.001*

Table 4: Intergroup tooth wear comparisons, normal occlusion and class II division 2 (MannWhitney test)
tooth Normal Class II division 2 occlusion Mean of scores SD Mean of scores SD P

Incisal/ occlusal surface Maxillary teeth 0.529 0.526 0.233 Laterals 0.776 0.542 0.2 Canines 0.388 0.537 0.633 First premolars 0.176 0.413 0.5 Second premolars Mandibular teeth 0.129 0.337 0.3 Second premolars Labial surfaces Mandibular teeth 0.059 0.237 0.2 Centrals 0.024 0.152 0.2 Laterals 0.047 0.213 0.166 Second premolars 0.188 0.393 0.5 First molars *Statistically significant at P < 0.05

0.43 0.007* 0.407 0.005* 0.615 0.045* 0.731 0.013* 0.479 0.035*

0.407 0.024* 0.406 0.001* 0.379 0.037* 0.508 0.001*

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Clinical significance of sella

Clinical significance of sella turcica morphologies and dimensions in relation to different skeletal patterns and skeletal maturity assessment
Kasim A. Obayis, B.D.S. (1) Ali I. Al-Bustani, B.D.S., M.Sc. (2)

ABSTRACT
Background: Sella turcica is a saddle-like structure based on the roof of the sphenoid bone and has an important role in orthodontic diagnosis and treatment planning. The aims of the study were to assess sella shape and size in an adolescent Iraqi sample in different skeletal classes and to verify the possibility of clinical application of sella turcica in skeletal maturity estimation. Materials and Methods: The study sample composed of (140) Iraqi adolescent subjects aged 10-16 years (91 females, 49 males); every subject had true lateral cephalometric radiograph. The sample was subjected to 2 classifications: the 1st included three skeletal classes according to ANB angle, and the 2nd included accelerative and decelerative groups according to maturity indicators of cervical vertebrae seen radiographically. In each classification, sella size was measured using three linear measurements (S.length, S.depth, and S. diameter). Results: Most of sella turcica measurements were not different statistically among the skeletal classes, and that specific sella turcica linear measurements can not be obtained for each specific skeletal class throughout the pubertal period. Normal sella was the predominant over the other morphological aberrations in both classification systems, while these morphologies occurred more frequently in class II and III. Sella depth and diameter were significantly higher in the decelerative than accelerative group, while non significant difference was found concerning sella shapes between the two groups. Conclusions: It was concluded that Sella depth and sella diameter measurements can be utilized clinically for pubertal growth phase determination, while sella morphology can not be diagnostic for the accelerative and decelerative pubertal growth phases. Keywords: Sella Turcica, Pubertal growth, Skeletal Maturity. (J Bagh Coll Dentistry 2012;24(2):120-126).

INTRODUCTION
Several landmarks within the cranium have been determined to act as reference points when tracing cephalometric radiographs. These landmarks are used to measure positions of structures (such as the maxilla or mandible) in relation to the cranium, or to themselves. The benefits gained from studying these structures serve: in assisting the orthodontist during diagnosis, as a tool to study growth, and in evaluation of orthodontic treatment results.(1) One of the most commonly used cranial landmarks for cephalometric tracing is sella point. This point is located in the centre of the sella turcica, with the turcica housing and protecting the pituitary gland in the cranial base.(2) Any abnormality or pathology in the gland could manifest from an altered shape of the sella turcica and/or a disturbance in the regulation of secretion of glandular hormones. (3-6) The anatomy of the sella turcica has been described as being variable.(7) Morphologically, three basic types oval, round, and flathave been classified, the oval and round types being the most common. During embryological development, the sella turcica area is a key point for the migration of the neural crest cells to the frontonasal and maxillary developmental fields.(8)
(1) M.Sc. Student, Department of Orthodontics, Dental College, University of Baghdad. (2) Assistant professor, Department of Orthodontics, Dental College, University of Baghdad.

For this reason, it is very important to study the effect of puberty (a period of significant body changes) on the normal morphology of this landmark clearly in a young sample, as it is studied in an adult sample, since this has a great importance in orthodontic diagnosis and treatment planning. Previously, when studying the sella turcica size (length, depth and diameter) and its relation to different skeletal patterns, no statistically significant correlation between facial type and the mean sella turcica area of the pituitary fossa had been presented.(9) However, Alkofide (1) when evaluated skeletal type and linear dimensions of sella turcica, a significant difference was found. When comparing skeletal class II and class III subjects, a significant difference was observed between the diameter of the sella turcica in both skeletal classes which may be attributed to genetic factors. Although the morphology and dimensions of sella turcica have been studied by previous researchers on adult Iraqi samples (10,11), until now no Iraqi study has been done to evaluate the linear dimensions and morphological structure of sella turcica in an adolescent Iraqi sample. Although no significant differences had been obtained between males and females in terms of mean linear dimensions of the sella turcica, previous studies (1,12,13) found a significant effect of age on

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sella turcica dimensions. So the present study was the first Iraqi study that evaluated the linear dimensions and morphological structure of sella turcica in an adolescent Iraqi sample, and their relationship to different skeletal patterns. Furthermore, this study was (for the 1st time) attempted to test the possibility of clinical employment of Sella Turcica in pubertal growth estimation.

MATERIALS AND METHODS


The sample The sample of this study consisted of radiographs for patients who were attending the preventive and orthodontic clinics at the teaching hospital of the College of Dentistry Baghdad University seeking paedodontic and orthodontic treatments. The sample was all of Iraqi origin, with an age ranging between 10-16 years. Out of 185 subjects examined, only 140 subjects (49 males and 91 females) met the inclusion criteria including no history of systemic disease (clinically healthy patient) or trauma in the craniofacial complex, no syndromes (clefts of the lips and palate), and no history of previous orthodontic treatment. Every subject has to be free from any congenital or acquired malformations of the cervical vertebrae (seen radiographically).(14) The sample has been subjected to two classification systems. 1st, according to ANB angle (15-17) into skeletal class I (13 males, 38 females), class II (20 males, 20 females), and class III (16 males, 33 females). 2nd, according to Maturity Indicators of Cervical Vertebrae (CVMI) (14) into accelerative (56) and decelerative (43) groups respectively. In the 2nd classification system, by excluding the easily recognized skeletal (I and VI) stages at the extremes of pubertal growth stages from the total radiographs, the total sample (140) became (99) radiograph.

METHOD
Cephalometric Analyses All Lateral Cephalometric Images were analyzed by an AutoCAD program (version 2007) to measure the ANB angle and to calculate the linear measurements of Sella Turcica. Size of Sella Turcica According to Silverman (18) and Kisling (19) the following lines were measured to determine the size of the Sella Turcica, all the reference lines used were situated in the midsagittal plane (figure 1):

A) The length of the Sella Turcica: Was measured as the distance from the Tuberculum Sellae (TS) to the tip of Dorsum Sellae (DS). B) The depth of Sella Turcica: Was measured as a perpendicular from the line mentioned above to the deepest point on the floor of the fossa (BPF). C) The anteroposterior greatest diameter of the Sella Turcica: Was measured from the Tuberculum Sellae (TS) to the furthest point on the posterior inner wall of the fossa (SP). Shape of Sella Turcica For the assessment of the morphological aberrations of the sella turcica (after enlargement of its view), in addition to the normal morphology of sella turcica traced in (figure 2); the different morphological appearances of the sella turcica described by Axelsson et al. (13,20) (figure 2), were used to classify sella shapes in the current study. The six morphological variations that are rated as normal included oblique anterior wall, sella turcica bridging, double contour of the floor, irregularity (notching) in the posterior part of the dorsum sellae, extremely low sella turcica, and pyramidal shape of the dorsum sellae. Skeletal Maturation Assessment The second part of the study has concerned with verifying the possibility of using the sella turcica for pubertal growth estimation by depending on a method of skeletal maturation assessment using the Maturity Indicators of Cervical Vertebrae. This method has been developed by Hassel and Farman (14) (CVMI). They described certain criteria for assessing maturational changes on the second, third, and fourth cervical vertebrae, which can be visualized on the lateral cephalograms even if a thyroid protective collar has been worn during radiation exposure. The two skeletal stages (stages I and VI) represent the extremes of the pubertal growth period, which can be very easily diagnosed clinically by the orthodontist. Greater efforts were, therefore, done to concentrate on subjects at the skeletal stages which require certain maturity indicators for their determination, specially skeletal stages III and IV. For more facility and practicality, the six pubertal growth stages have been condensed only into two growth phases or stages (accelerative and decelerative),i.e., by excluding the two skeletal stages (stages I and VI) at the extremes of the pubertal growth period, the two accelerative (stages II and III) and the two decelerative (stages IV and V) were combined to represent the accelerative and decelerative groups, respectively. (14,21,22) Furthermore, since males and females pass during puberty through the same physiological sequence,i.e., both progress towards skeletal

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maturity with advancement of age and growth; therefore, the total sample has been classified into accelerative and decelerative groups without male and female classification. Statistical Analysis The statistical analysis included: I. Descriptive Statistics: Including (Mean value, Standard deviation, Number and Percentage, and Statistical tables). II. Inferential Statistics: Including (ANOVA test, LSD test, Independent t-test, and Likelihood Ratio test (Lx2))

RESULTS AND DISCUSSION


The literature involves different age ranges, with the puberty may begin as early as 9 or 10 years, and may end as late as 18 or 19 years of age. By selecting the 10-16 years age range, therefore, reconcilement of the different findings about the pubertal timing has been done. (22,23) Size measurements of the sella turcica have, to-date, almost solely been used as a diagnostic tool concerning expanding tumors or tumor-like processes in the pituitary gland. (1,24,25) Statistically, there were non significant gender differences in all sella turcica linear measurements (S. length, S. depth and S. diameter) in skeletal class II and III, while the two measurements (S. depth and S. diameter) were significantly higher in females than in males dealing with skeletal class I (table 1). This may be explained by: 1st, The explicit discrepancy in gender distribution in this skeletal pattern.2nd, The earlier pubertal growth spurt in females which may influence their sella measurements. Genetic factors most likely play a leading role in male-female growth differences. The marked advancement of girls over boys in the rate of maturation is attributed to the delaying action of the Y chromosome in males. By delaying growth, the Y chromosome allows males to grow over a longer period of time than females, therefore making possible greater overall growth. (26) On the other hand, non significant gender mean difference was found concerning the sella length in class I. This may be attributed to a greater pubertal growth influence on the vertical than on the anteroposterior (Sella length) dimension. By comparing the subjects linear dimensions of sella turcica with normative data from the literature, the former result was in agreement with Alkofide (1) and Yassir et al.(10), while the latter result was in agreement with Silverman (18), Chilton et al.(27), and Elster et al.(28) who revealed that the pituitary fossa of males tended to be larger than that of females during childhood. After that, due to the pubertal growth spurt in females which begins 2

years earlier than males, a significant change in pituitary fossa size occurs in females from 11 to 14 years of age. Thereafter, the late growth acceleration in males, which is usually about 2 years later than females, results in an approximate equalization in sella area in both genders. On the other hand, by comparing sella measurements among the skeletal classes, it was found that the sella depth was significantly higher in class I than in class II (table 1). This finding may be attributed to genetically determined growth factors. According to this study result, specific sella turcica linear measurements can not be obtained for each specific skeletal class throughout the pubertal period. In comparison with adult studies MeyerMarcotty (6), Yassir et al. (10), and Al-Ani (11), it could be demonstrated that the length, depth, and diameter of the sella turcica region of all examined patients in this study tended to be smaller, a finding that confirms the effect of age on sella measurements. Investigations concerning the sella turcica have not only focused on size, but also on morphology. (1,2,6,10,11,13,20,29) No previous studies concerning sella morphology have mentioned the gender difference in each skeletal class separately during pubertal period alone, rather previous studies have either compared between males and females as a total sample (Yassir et al.(10) and Axelsson et al.(13,20)) or they compared between the classes (as a total in each class) without giving gender difference (Meyer-Marcotty et al.(6); Yassir et al.(10); Abdel-Kader (30)). Furthermore, these studies used the frequency and percentage as a baseline for comparison, i.e. descriptive statistics only, and they did not use inferential statistical analyses between genders and among the classes. Normal sella turcica was the predominant shape over the other morphological variations in all skeletal classes (table 2). This predominance can be attributed to growth and development basis. Sella turcica is expected to become oval to more round (i.e. normal) with craniofacial growth progression. This is true if we follow the normal growth and development of sella turcica, as it appears as a shallow-like depression at the fetal stage, while as the growth of the cranium proceeds it becomes slightly oval to round at the permanent dentition stage (at adolescence). This result comes to be in agreement with (Alkofide (1); Yassir et al.(10); Al-Ani (11) and Axelsson et al.(13,20)) their results showed that a normal sella turcica morphology was seen in two-thirds of the subjects, while the remainder showed dysmorphological appearances.

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Any deviation from the above mentioned sella growth and development map can account for the occurrence of these shapes. Statistically, only in class III, Likelihood Ratio test showed significant difference between males and females for the different shapes of sella turcica. Skeletal class III can be considered as a type of craniofacial deviation in which growth pattern is abnormal. Furthermore, greater percentages of males are affected by this type of malocclusion than females. So, if we consider morphological sellar aberrations as a deviation from the normal development of sella turcica, abnormal sella may occur more frequently in this class and mostly in males. The predominance of non significant sella morphology differences between genders enabled dealing with the subjects as a total sample within each skeletal class. Although multiple comparisons were made among the classes, a significant difference only was present between class II and III (table 3). Genetically determined growth factors may have a role. Formation and development of the sella turcica and dental structures share, in common, the involvement of neural crest cells. In fact, the anterior part of the sella turcica is believed to develop mainly from neural crest cells, (31,32) so any structural deviations in the anterior wall are believed to be associated with specific deviations in the facial skeleton.(33) Moreover, During embryological development, the sella turcica area is a key point for the migration of the neural crest cells to the frontonasal and maxillary developmental fields. (8) The majority of normal sella turcica appeared to be present in skeletal class I followed by class III and then by class II. This may be attributed to structural adaptation phenomenon. The sella turcica structural development is influenced by growth and development of the surrounding structures (i.e. anterior and posterior cranial bases, brain, and nasomaxillary complex). Normal and harmonious growth behavior of these structures would result in a normal sella shape, while any deviation from this harmonious growth might lead to sella turcica morphological aberrations which occurred mostly in class III. Determining the pubertal growth phase (accelerative or decelerative) is an important aim clinically, irrespective of the specific stage of that phase. Dealing with (table 4) there was non significant difference of sella mean length between the accelerative and decelerative groups. Conversely, the other two measurements (S. depth and S. diameter) were higher in the decelerative than accelerative group. Statistically, there were significant and highly significant differences in

the mean values of sella (depth and diameter) between groups, respectively. This finding may be related to growth and age progression background. Bone apposition on the anterior part of the interior surface of the sella turcica is ceased at an early age, whereas resorption is continued for a long time on the distal part of the sella floor and on the posterior wall.(35-38) Furthermore, the anterior wall of the sella turcica reaches stability at 5-6 years of age and the tuberculum sella and the posterior wall of the sella turcica stop growing at ages of 18 years in males and 16 years in females (at the ends of pubertal growth).(39) This can give us two important findings. First, the reference point 'sella' would, therefore, with growth and age progression, be displaced backwards and downwards. Second, Sella depth and diameter would be increased with age and at specific time females are having higher sella measurements than males. Related previous studies,(1,2,9,12,13,18,27,29,40) have dealt with the age factor, rather than pubertal growth spurt. They mostly confirmed two findings: 1st, sella size increases significantly with age; 2nd, sella depth and diameter are the most influenced linear measurements by the age factor in comparison with sella length. According to this study result, sella depth and sella diameter measurements can be utilized clinically for pubertal growth phase determination. This requires larger sample collection so that cut-off points and intervals (ranges) can be estimated for the accelerative and decelerative stages.

REFERENCES
1. Alkofide E. The shape and size of the sella turcica in skeletal Class I, Class II and Class III Saudi subjects. Eur J Orthod 2007; 29(5): 45763. 2. Andredaki M, Koumantanou A, Dorotheou D, Halazonetis DJ. A cephalometric morphometric study of the sella turcica. Eur J Orthod 2007; 29(5): 44956. 3. Elster AD. Imaging of the sella: anatomy and pathology . Seminars in Ultrasound, CT, and MRI 1993a; 14: 182 194. 4. Elster AD. Modern imaging of the pituitary. Radiology 1993b; 187: 114. 5. Pisaneschi M, Kapoor G. Imaging of the sella and parasellar region. Neuroimaging Clinics of North America 2005; 15: 203 219. 6. Meyer-Marcotty P,Tobias R, Angelika S. Bridging of the sella turcica in skeletalclass III subjects. European J Orthodontics 2010; 3: 148-153. 7. Teal JS. Radiology of the adult sella turcica. Bull Los Angeles Neurolog Soc 1977;42:11117.[Cited by: Meyer-Marcotty P, Tobias R, Angelika S. Bridging of the sella turcica in skeletal class III subjects. European J Orthodontics 2010; 3: 148-153].

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8. Kjr I, Keeling JW, Fischer-Hansen B. The prenatal human craniumnormal and pathologic development. Munksgard, Copenhagen 1999. 9. Preston CB. Pituitary fossa size and facial type. American J Orthodontics 1979; 75(3): 25963. 10. Yassir YA, Nahidh M, Yousif HA. Size and Morphology of Sella Turcica in Iraqi Adults. AlMustansiria Dent J 2010; 7(1):23-30. 11. Al-Ani MK. Sella Turcica Features and its relation to Anterior Facial Skeleton In Iraqi Sample Aged 18-30 Years, M. Sc. Thesis, Baghdad University 2010. 12. Choi WJ, Hwang EH, Lee SE. The study of shape and size of normal sella turcica in cephalometric radiographs. Korean J Oral Maxillofac Radiology 2001; 31(1): 43 9. 13. Axelsson S, Storhaug K, Kjr I. Post-natal size and morphology of the sella turcica-longitudinal cephalometric standards for Norwegians between 6 and 21 years of age. Eur J Orthod 2004; 26(6): 597 604. 14. Hassel B, Farman AG. Skeletal maturation evaluation using cervical vertebrae, Am J Orthod Dentof Orthop 1995; 107(1): 58- 66. 15. Foster TD. A textbook of orthodontics. 3rd ed. Oxford: Blackwell Scientific Publication 1990; p: 1, 78, 95-6. 16. Rani MS. Synopsis of orthodontics. 1st ed. Delhi: AITBS Publishers Distributors 1995; p:113. 17. Mitchell L, Carter NE, Doubleday B. An introduction to orthodontics. 2nd ed. Oxford: Oxford University press 2004; p: 60. 18. Silverman FN. Roentgen standards for size of the pituitary fossa from infancy through adolescence. Am J Roentgenology 1957; 78(3):451 60. 19. Kisling E. Cranial morphology in Downs syndrome. A comparative roentgen cephalometric study in adult males, Thesis, Munksgaard and Copenhagen 1966. 20. Axelsson S, Storhaug K, Kjaer I. Post-natal size and morphology of the sella turcica in Williams syndrome. Eur J Orthod 2004b; 26(6): 613 21. 21. Fishman LS. Radiographic evaluation of skeletal maturation; a clinically oriented method based on hand wrist films. Angle Orthod 1982;52:88-112. 22. Al-Bustani AI. The Dental Maturation and Chronological Age in Relation to the Skeletal Maturation, as Indicators for the Pubertal Growth Estimation [A New Approach in Clinical Orthodontics], M. Sc. Thesis, Baghdad University 2001. 23. Hgg U, Taranger J. Maturation indicators and the pubertal growth spurt, Am J Orthod 1982; 82(4): 299309. 24. Weisberg LA, Zimmerman EA, Frantz A. Diagnosis and evaluation of patients with an enlarged sella. Am J Med 1976; 61:590-6. 25. Friedland B, Meazzini MC. Incidental finding of an enlarged sella turcica on a lateral cephalogram.

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American J Orthodontics and Dentofacial Orthopedics 1996; 110(5): 50812. Bishara SE. Textbook of orthodontics, W.B Saunders Company 2001; P: 31. Chilton LA, Dorst JP, Garn SM. The volume of the sella turcica in children: new standards. Am J Roentge 1983; 140(4):797801. Elster AD, Chen MY, Williams DW, Key LL. Pituitary gland: MR imaging of physiologic hypertrophy in adolescence. Radiology 1990; 174: 681 9. Najim AA. A Cephalometric Study of Sella Turcica Size and Morphology among Young Iraqi Normal Population in Comparison to Patients with Maxillary Malposed Canine, M. Sc. Thesis, Baghdad University 2011. Abdel-Kader HM. Sella turcica bridges in orthodontic and orthognathic surgery patients. A retrospective cephalometric study. Austra Orthod J 2007; 23: 305. Miletich I, Sharpe PT. Neural crest contribution to mammalian tooth formation. Birth Defects Research. Part C, Embryo Today: Reviews 2004; 72 : 200 12. Morotomi T, Kawano S, Toyono T, Kitamura C, Terashita M, Ushida T, Toyoshima K, Harada H. In vitro differentiation of dental epithelial progenitor cells through epithelial-mesenchymal interactions. Archives of Oral Biology 2005; 50 : 695 705. Kjr I, Keeling J W, Reintoft I, Nolting D, Fischer Hansen B. Pituitary gland and sella turcica in human trisomy 21 fetuses related to axial skeletal development. American J Medical Genetics 1998; 80 : 494500. Bjrk A. Facial growth in man studied with aid metalic implants. Acta odont Scand 1955; 13:9-34. Melsen B. The cranial base: the postnatal development of the cranial base studied historically on human autopsy material . Acta Odontologica Scandinavica 1974;32: (Suppl. 62): 57 71. Bjrk A, Skiller V. Normal and abnormal growth of the mandible. A synthesis of longitudinal cephalometric implant of the studies over a period of 25 years. Eur J Orthod 1983; 5:1-46. Enlow DH. Postnatal Craniofacial Growth and Development, In McCarthy JG (ed.), Plastic Surgery, Vol. 4, Cleft Lip and Palate and Craniofacial Anomalies, Philadelphia, W.B. Saunders Company 1990; p: 213-215. Becktor JP, Einersen S, Kjaer I. A sella turcica bridge in subjects with severe craniofacial deviations. Eur J Orthod 2000; 22: 6974. Tetradis S, Kantor ML. Prevalence of skeletal and dental anomalies and normal variants seen in cephalometric and other radiographs of orthodontic patients. Am J Orthod Dentofacial Orthop 1999: 116(5): 573-7.

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


sk. class Sella length Sella depth Sella diameter Sex n Mean SD P.value sex n Mean SD P.value sex n Mean SD P.value 13 6.26 0.8 13 9.11 1.57 13 6.94 1.8 .001** .006** 38 10.3 1.2 cl. I 38 6.54 1.33 .39 (NS) 38 7.52 1.25 (HS) (HS) total 51 7.2 1.27 total 51 10 1.39 total 51 6.64 1.46 20 6.7 1.06 20 9.5 1.33 20 7.08 1.69 0.7 0.36 0.48 20 6.34 1.37 20 9.79 1.27 cl. II 20 6.88 1.5 (NS) (NS) (NS) total 40 6.52 1.22 total 40 9.64 1.29 total 40 6.98 1.58 16 6.41 1.25 16 9.17 1.57 16 6.64 2.08 0.3 0.26 0.1 33 6.9 1.47 33 9.92 1.42 cl. III 33 7.17 1.45 (NS) (NS) (NS) total 49 6.74 1.41 total 49 9.68 1.5 total 49 6.99 1.67 ANOVA 0.46 (NS) ANOVA 0.041* ANOVA 0.37 (NS) Class I- Class II Class I- Class III Class II- Class III Mean difference P-value Mean difference P-value Mean difference P-value 0.68 0.015* 0.46 0.08 (NS) -0.22 0.44 (NS) Sella depth Variable

Table 2: Number distribution and percentage of Sella shape in skeletal classes with gender difference.
Class I (n=51) Class II (n=40) Class III (n=49) Male female male female male female p-value p-value p-value n % n % n % n % n % n % 13 65% 10 50% 7 43.75% 23 69.70% Normal 7 53.80% 29 76.30% 0.194 0.429 0.035 3 15% 2 10% 3 18.75% 1 3% Oblique 2 15.40% 1 2.60% 3 15% 4 20% 3 18.75% 1 3% Bridge 3 23.10% 2 5.30% 0 0.00% 2 10% 0 0.00% 0 0.00% Notching 0 0.00% 2 5.30% 0 0.00% 0 0.00% 0 0.00% 5 15.20% Double 0 0.00% 1 2.60% 0 0.00% 1 5% 2 12.50% 2 6.10% Pyramidal 1 7.70% 3 7.90% 1 5% 1 5% 1 6.25% 1 3% 0 0.00% 0 0.00% Low NS 20 100% 20 100% NS 16 100% 33 100% S Total 13 100% 38 100% S. shape

Table 3: Number distribution and percentage of Sella shape for total sample with shape difference among skeletal classes.
Skeletal class Shape Sella shape Class I Class II Class III C.S difference n % n % n % Normal 36 70% 23 57.50% 30 61.20% Oblique 3 5.90% 5 12.50% 4 8.20% Cl. I- II P-value 0.205 NS Bridge 5 9.80% 7 17.50% 4 8.20% Notching 2 3.90% 2 5.00% 0 0.00% Cl. I- III P-value 0.162 NS Double 1 2.00% 0 0.00% 5 10.20% Pyramidal 4 7.80% 1 2.50% 4 8.20% 0 0.00% 2 5.00% 2 4.00% Cl. II- III P-value 0.048* S Low 51 100% 40 100% 49 100% Total

Table 4: Descriptive statistics of S. Turcica linear measurements for Pubertal growth stages with mean difference statistics.
Mean difference (d.f.=97) P-value t-value 0.682 0.41 (NS) .020* -2.365 (S) .009** -2.677 (HS) Stage of growth Decelerative(N=43) Accelerative(N=56) Variable SD Mean Max. Min. SD Mean Max. Min. Sella 1.4 6.81 9.86 4.29 1.53 6.93 11.46 4.39 length Sella 1.37 7.32 9.78 3.8 1.34 6.67 9.66 3.43 depth Sella 1.16 10.4 14.08 7.03 1.25 9.74 13.96 7.26 diameter

NS = P> 0.05 Non significant. * = 0.05 P > 0.01 Significant. ** = P 0.01 highly significant.

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SP

Figure 1: Normal sella turcica morphology and reference lines used for measuring sella size. TS, tuberculum sella; DS, dorsum sella; BPF, base of the pituitary fossa; SP, sella posterior; white line, length of sella; red line, diameter of sella; blue line, depth of sella.

Figure 2: Tracings and details from lateral cephalograms of the different morphological types of sella turcica: (A) Double contour of the floor, (B) extremely low sella turcica, (C) Sella turcica bridging, (D) Irregularity (notching) in the posterior part of the dorsum sellae (E) oblique anterior wall and (F) Pyramidal shape of the dorsum sellae.

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Clinical performance comparison

Clinical performance comparison of a clear advantage series II durable retainer with different retainers' types
Mustafa M. Al-Khatieeb, B.D.S., M.Sc. (1)

ABSTRACT
Background: The orthodontic retainers are either fixed or removable. Each has its own advantages and disadvantages. The goal of the current study was to evaluate the new Clear Advantage Series II durable thermovacuum formed invisible orthodontic retainer material and compare the clinical performance of such retainer with the most standard types of retainers (convention Clear Advantage Series I thermo-vacuum formed invisible retainer, Hawley, and the fixed lingual bonded retainers). The conducted study is the first attempt to evaluate and compare the clinical performance of different retainers' types. Subjects and methods: Twenty finished fixed orthodontic patients starting the retention phase were divided into four groups. Each group consisted of five patients (3 females and 2 males), mean age ranged 18-30 years old. Members of the first group were given the new thermo-vacuum formed invisible Clear Advantage Series II durable retainer material (CII), While the second, third, and fourth groups were given standard thermo-vacuum formed invisible Clear Advantage Series I retainer material (CI), Hawley retainer (HR), and fixed lingual bonded retainers "cuspid to cuspid"(FR), respectively. Ten variables were applied on the twenty patients to evaluate the clinical performance of the four retainers' types, the ten variables were evaluated and judged by the operator with the patient as three nonparametric categorical descriptions: superior (+), acceptable (), and inferior (-) properties. Results: It was found that patients were compliant with all types of retainers initially, and the compliance decreased at a much faster rate with both types of themo-vacuum formed retainers (CII and CI) than with HR and FR retainers, and patient's compliance is greater with HR and FR retainers than with CII and CI retainers. A comparison of the total variables of the clinical performance at total time intervals using chi-square showed that there was a significant difference (P<0.05) in the acceptable categorical description between CII and CI retainers and very high significant difference (P<0.001) between CII, HR, and FR retainers. Conclusion: it was found that the new thermo-vacuum formed Clear Advantage Series II durable retainer showed a combination of removable, comfortable, aesthetic, better speech, superior retention, relatively not producing bad taste and odor, hygienic, least soft tissue irritability, superior construction and chair-side time, and durable, it will be more favorable clinical performance appliance to both the patient and the orthodontist. Keywords: Clinical performance, Clear Advantage Series II Durable, Retainers. (J Bagh Coll Dentistry 2012;24(2):127136).

INTRODUCTION
In orthodontics, although the patient may feel that treatment is complete when the appliances are removed, an important stage lies ahead, which is the retention phase, retention has been defined by Moyers (1) as the process of maintaining the moved teeth into the new position long enough to aid in stabilizing their correction. Relapse has been defined as a return of teeth to their original position or a shift in arch relationship after the end of treatment, because teeth tend to move back to their pre-treatment positions if they are not retained (2-4). The etiology of relapse is multifactorial and can be divided into three main areas: physiological recovery, unfavorable growth, or "true relapse" due to the placement of the teeth in an unstable position (4). Reitan (5) in 1967 showed that periodontal ligament takes 232 days to reorganize and can derotate teeth after one years. The periodontal ligament requires three to four months' masticatory stimulation for organization of its fibers.
(1) Lecturer, Department of Orthodontics, Dental College, University of Baghdad.

In addition, research has shown that alveolar bone is laid down after one month and supracrestal fibers require one year to remodel, therefore, retention and relapse are considered as vital issues of a complete and a successful orthodontic treatment (2). There are literatures on retention and post-treatment relapse, which have been reviewed in some depth (5-8). In orthodontic, there are grossly two types of orthodontic retainers: removable (commonly temporary), and fixed (commonly permanent) (911) . A temporary retainer is designed for a relatively limited retention period to allow for the reorganization of the gingival & periodontal tissues (8). Henry Baker used maxillary and mandibular vulcanite removable retainers with labial wires, but the vulcanite was not adapted to the teeth. Instead, the teeth were prevented from moving lingually by metallic spurs embedded in the vulcanite (12). The retainers of Chartes A. Hawley (13) in 1919 were an improvement over Baker's in that the base material was flowed against the lingual surfaces, thus helping to prevent rotations. In 1930s, vulcanite was replaced by acrylic, and till now the orthodontists are using the Hawley retainer and its many known modification (12-14). The invisible retainers was

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developed by Robert Pointz (15) in 1971, later on Essix retainers were introduced by Sheridan et al (16) in 1993. Typically such invisible retainers are formed from a sheet of thin Biocryl, or other similar material that is heated & formed by suction or pressure on to a work model of the dentition (15-18). The purpose of the current study was to evaluate the new Clear Advantage Series II durable retainer and compare the clinical performance of such retainer with the most standard types of retainers (convention Clear Advantage Series I thermo-vacuum formed invisible retainer, Hawley, and the fixed lingual bonded retainers).

SUBJECTS AND METHODS


Twenty finished fixed orthodontic patients attended a private clinic in Baghdad city, starting the retention phase were selected from 29 patients after discussion the study with them from ethical approval point of view, and only those willing to provide complete co-operation were enrolled in the study and fully informed consents were taken, the twenty patients were divided into four groups. Each group consisted of five patients (3 females and 2 males), mean age ranged 18-30 years old. Patient exclusion criteria: 1. Craniofacial anomalies, symptoms of temperomandibular joint disorders, history of orthognathic surgery, or bad habits. 2. Unsatisfied patients to the final orthodontic fixed treatment objectives. 3. Unavailable patients for long term (1 year) follow-up evaluation. Methodology: The treatment protocol was as follow: All participants were previously treated with Roth system upper and lower fixed orthodontic appliances (Bracket's slot size 0.022", Pyramid Orhodontics, CA; USA). An alginate impressions (Tropicalgin-normal setting Zhermack ; Italy) were taken by assorted sizes rim lock trays (Frontier Dental Industrial Co., China) for the patients' upper and lower dental arches then poured with type four thixotropic die stone (Elite Stone - Zhermack; Italy) after considering the manufacturer instructions. All retainers were fabricated by the same private laboratory. Members of the first group were given the new thermo-vacuum formed invisible Clear Advantage Series II durable retainer material, thermal forming coping polypropylene; 0.040 of an inch (OrthoTechnology-Tampa, Florida; USA). While the second, third, and fourth groups were given standard thermo-vacuum formed invisible Clear Advantage Series I thermal forming splint/copolyester retainer material; 0.040 of an
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inch (OrthoTechnology-Tampa, Florida, USA), Hawley retainer fabricated with polymethylmethacrylate "powder and liquid" (Orthocryl, Dentaurum, Ispringen, Germany) and 0.7mm hard stain-less steel wire (Dentaurum, Ispringen, Germany), and fixed lingual bonded retainers "cuspid to cuspid" with assorted sizes (Ortho Matrix; USA) bonded with light activated orthodontic bonding system (Resilience , Ortho Technology-Tampa, Florida; USA), respectively, the retainers' materials were shown in figure 1. The Clear Advantage Series II thermo-vacuum formed durable invisible retainer, the Clear Advantage Series I thermo-vacuum formed standard invisible retainer, and the fixed bonded lingual retainer were placed on the same day as the fixed appliances were removed, while the Hawley retainers were placed one to seven days after the removal of the fixed appliances, the four types of retainers were shown in figures 2 to 5. Ten variables were applied on the twenty patients to evaluate the clinical performance of the four retainers' types, the ten variables were evaluated and judged by the operator with the patient as three non-parametric categorical descriptions: superior (+), acceptable (), and inferior (-) properties, these ten variables were. 1. Versatility: it indicates the adaptability and comfort of the patient to the retainer. 2. Aesthetic: It means the beauty and the invisibility of the retainer. 3. Speech: It indicates the effect of the retainer on speech. 4. Retention: It indicates the stability of the retainer during rest and animation. 5. Bad taste and odor: It refers if the retainer produces a bad taste and smell. 6. Caries risk: It refers to the hygienic property of the retainer. 7. Soft tissue irritability: It refers to the ability of the retainer to produce irritation to the soft tissue (gingival, lip, cheek, and tongue). 8. Construction times: It refers to how much time does it need to construct the appliance till insertion inside the patient's mouth, noted as superior (short time), acceptable (intermediate time), and inferior (long time). 9. Chair-side time: It refers to how much time does it need to place, fit, or bond the retainer at each visit, also it involves the time needed for repairing the appliance. 10. Failure of retention material: It refers to the durability of the retainer's material inside the patient's mouth. Without crack, perforation, fracture, or debonding.

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The clinical performance of the new Clear Advantage Series II durable thermo-vacuum formed invisible retainer was evaluated at the time of retainer insertion, three months, six months, and one year post-insertion follow-up (19,20) in comparison with the three of the most standard and commonly used retainers; convention Clear Advantage Series I thermo-vacuum formed invisible retainer, Hawley, and the fixed lingual bonded retainers. All patients received upper and lower retainers, the invisible retainers were full coverage type, and the patient should wear the removable retainer full day time (except during meals for thermo-vacuum formed retainers) for six months, and then at night only for the next six months (21). Statistical analysis: The data were collected and subjected to computerized statistical analysis using statistical Package for Social Science computer software (SPSS, version 17), in which the description for the non-parametric categorical variables represented by observed number and percentage of occurrence, while the inferential statistics included the use of Chi-square for comparison of the categorical data among the four types of retainers. Probability levels of less than 5%, 1%, and 0.1% were regarded as statistically significant, highly significant, and very highly significant, respectively. Method error: It was calculated to determine the reproducibility and reliability of the categorical descriptions of clinical performance, the categorical descriptions of five patients were evaluated two times, first by the researcher, and second time by another observer. Kappa test (GraphPad Software, Inc.; USA) was used to evaluate the inter-observer agreement, it was found equal to 0.8 which indicates a very good strength of agreement. (4,22).

RESULTS AND DISCUSSION


There are insufficient data on which to base our clinical practices on retention present, several retainer designs have examined over time, with various retention protocols to minimize relapse (19,23-25) . Because of the lack of scientific evidence on retention protocols, it appears that previous recommendations are based largely on personal preference and non-scientific criteria (4,25). The clinical performance of different retainers' types is a vital area of orthodontic research, and it should be given priority on our concern. As far as being aware, no research has been published that addresses the evaluation of the clinical performance of different retainers' types. Many studies conducted onto survey the orthodontic trends over the past 25 years in
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Australia, New Zealand, United States and United Kingdom to identify consistencies in retention procedures and found that the most commonly used retainers were invisible retainers (vacuumformed) and canine to canine bonded lingual retainers. Hawley retainers declined in use from 1986 to 2011, whereas invisible retainers and fixed bonded canine to canine retainers increased (25-28) . Therefore, in the current study, the new retainer (Clear Advantage Series II durable retainer) was compared with the most commonly used retainers in orthodontics (standard thermovacuum formed invisible retainer, Hawley, and fixed bonded lingual retainers). On the other hand, it is very important to explain fully the importance of retainers and of proper handling and regular checkups to patients (4). Patients need to be recalled after different time intervals in order to instruct, checkup, adjust, and remove any discomfort, therefore, in the current study, different time intervals ( At time of retainer insertion, three months, six months, and one year post-retainer insertion) were selected to evaluate the clinical performance of these retainers (19,20). Tables one to four described the variables' characteristics of clinical performance. Regarding the versatility (comfort and adaptability), the Clear Advantage Series II durable invisible retainer (CII) showed that there was an inferior categorical description property expressed by a low observed numbers and percentages of occurrence at the time of retainers insertion, the superior and acceptable categorical descriptions increase after three months, then became the same description after six months and one year postretainer insertion, while the Clear Advantage Series I standard thermo-vacuum formed invisible retainer (CI) showed an increase in the superior and acceptable categorical descriptions from the time of insertion to three months postinsertion, this may be due to adaptation of stomatognathic system to the new appliance inserted inside the patient's mouth, the inferior description increases from six months to one year post-insertion, this may be due to cracks produced at the margins of the retainer that can reduce the adaptation and comfort of the patient to this type of retainer. The Hawley retainer (HR) showed an increase in the superior and acceptable categorical descriptions from time of insertion to the three months post-insertion due to the adaptation process, while the inferior description increases from six months to one year post-insertion, this may be due that such type of retainer contains thick and bulk acrylic base plate and orthodontic wires that are liable to deformation and need periodic adjustment, so the versatility decreased

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with time, so that it will negatively affect the adaptation and comfort. The fixed bonded lingual retainer (FR) showed an increase in the superior categorical description with time, this may also be due to adaptation of the tongue to the fixed bonded lingual retainer. Regarding the esthetic point of view the CII, CI, and FR showed high observed numbers and percentages of occurrence for superior and acceptable descriptions, this is due to the translucent property of clear invisible (CII and CI) retainers, even though the CII retainer is slight cloudy than the CI retainer, but when the CII retainer is subjected to heat during thermal vacuum forming process, such cloudiness is decreased and became unnoticeable when the CII is inserted inside the patient's mouth, so both types of clear invisible (CII and CI) retainers exhibited superior and acceptable properties, the fixed bonded lingual retainer (FR) was positioned lingually, therefore it exhibits better esthetic, while the HR showed an increase of the superior and acceptable categorical descriptions with time, this may be due to better psychological adaptation to the shape of this retainer. Regarding the speech, all types of retainers showed increase in the superior and acceptable categorical descriptions with time due to the adaptation of the patient's tongue and lips to the retainers with time factor, so phonetic improvement will occur. Regarding the retention, the CII and CI retainers showed superior categorical description, and not affected by time, because these retainers' types depend on negative pressure, accurate fitness, and interfacial forces to achieve their retention (3,4,23), while the HR showed increase in the inferior categorical description with time because such type of retainers had wires that need periodic adjustment, the FR showed also increase in the inferior property with time, this may be due to the increase of the bonding failure of FR with time, which can subsequently affect the overall retention of this type of retainer. Regarding the bad taste, the CII and CI retainers showed superior categorical description and not affected by the factor of time, while HR showed inferior description at time of insertion, this may be due to the residual monomer of methyl methacrylate, the inferior property decreases after three months and six months postinsertion, then the inferior property will increase after one year post-insertion, this may be due to microbial plaque accumulation at the acrylic base plate that can affect the taste and odor, this explanation agreed with other research (8) , the FR showed high inferior property at time of insertion,
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due to the bad taste of the etchant and primer, which can negatively affect the taste, then with time there will be an increase in the inferior property of bad taste and odor, due to unhygienic plaque accumulation property of this type of retainer (9,10). Regarding the caries risk, all types of removable retainers showed high observed numbers and percentages of occurrence of superior categorical description property and remained high with time, except the FR showed high inferior property with time because of difficulty in maintaining good oral hygiene with such type of retainer, while all removable retainers can be removed outside the patient's mouth, so it is better to perform a good oral hygiene maintenance with such type of retainers (9,10) . Regarding soft tissue irritability, CII and CI retainers showed high observed numbers and percentages of occurrence of the superior categorical description property and remained the same with time because both retainers' thickness were one millimeter and contained no wires, so less soft tissue irritability, while HR showed high inferior property and remained the same observed numbers and percentages after three months, six months , and one year post-insertion, because this type of retainers contained wires and relatively thick bulky acrylic base plate that can affect on the surrounding soft tissue. However, it is well known that the major advantage of HR is the ability of the patient to perform optimal oral hygiene care, the major disadvantage of such retainer is the acrylic base plate, which is basically thick and bulky, such bulk affects speech negatively, potentially toxic irritable and unhygienic upon prolong wearing (8), some authors said that HR allows vertical settling of the teeth (29-31). But settling of teeth should be carried out during the last phase of active treatment rather than in the retention period (30-32), the FR showed high observed number and percentage of the inferior categorical property and both increase with time, this may be due to the ability of this type of retainer to cause irritation to the surrounding soft tissue due to plaque retentive ability, on the other hand, the major advantage of the fixed retainer was the close relation between the bonded teeth, resulting in their consolidation to act clinically as a stable dental unit, such consolidation maintains the position of the dentition even in the presence of unfavorable or unbalanced soft tissue forces (9,33). Regarding the construction time, CII and CI invisible retainers showed high superior categorical property, because such retainers need

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

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concluded that HR and FR also exhibited the same overall clinical performance. In addition, it was found that patients were compliant with all types of retainers, and the compliance decreased at a much faster rate with both types of themovacuum formed retainers (CII and CI ) than with HR and FR. As a conclusion, patient's compliance is greater with HR and FR retainers than with CII and CI retainers, this agreed with other researches (25,38) .

REFERENCES
1. Moyers RE, Textbook of orthodontics. 4th ed. Chicago: Year Book Medical Publishers Inc, 1988; 326-327. 2. Lyotard N. Evaluation of short-term stability without retention: A pilot study [thesis], Cleveland: Case Western Reserve University, 2006. 3. Manish V, Eric H. Results of a survey based study to identify common retention practices in the United Sates. Am. J. Orthod. Dentofac. Orthop. 2010; 137(2): 170-177. 4. Thickett E, Power S. Clinical trial of thermoplastic retainer wear. Europ. J. Orthod. 2010; 32:1-5. 5. Reitan K. Clinical & histological observations on tooth movement during & after orthodontic treatment. Am. J. Orthod. 1967; 53: 721-745. 6. Blake M, Bibby K. Retention & stability: A review of the literature. Am. J. Orthod. Dentofac. Orthop. 1998; 114: 299-306. 7. Graber M., Varasdall RL, Vig KW. Orthodontics: Current principle & techniques. 4th Ed. St. Louis: Mosby: 2005; 1123-1152. 8. Balkhi KM. A non-acrylic removable cast retainer (AL-BALKHT TYPE). Saudi Dent. J. 1993; 5 (1): 26. 9. De Wide P, Kientghen J. Permanent retention: a justified orthodontic compromise. Rev. Beige. Med. Dent. 1989; 44: 55-69. 10. Zachrisson BU. Clinical experiences with directbonded orthodontic retainers: Am. J. Orthod. 1977; 71: 440-48. 11. Gill DS, Naini FB. Orthodontics principles & practice, 1st Ed. Wiley-Blackwell. 2011, 354-364. 12. Norman W. Orthodontics in 3 millennia chapters 5: the American Board of Orthodontics, Albert Ketcham, and early 20th-century appliances. Am. J. Orthod. Dentofac. Orthop. 2005; 128 (4): 535-540. 13. Hawley CA. A removable retainer. Int. J. Orthodont. Oral Surg. 1919; 2: 291-98. 14. Nikolai RI, Horner KD, Blackwell DA, Carr RJ. On the design of looped orthodontic retainer wires. Angle Orthod. 1991, 61: 211-20. 15. Pointz RJ. Invisible retainers. Am J. Orthod. 1971; 59: 266-272. 16. Sheridan JJ, Ledoux W, McMinn R. Essix retainers: fabrication and supervision for permanent retention. J. Clin. Orthod. 1993; 27:37-45. 17. Nahoum HI. The vacuum formed dental contour appliance. New York State Dent. J. 1964; 9: 385-390. 18. Mc Namara JA, Kramer KL, Juenker JP. Invisible retainers. J. Clin. Orthod. 1985; 19: 570-578.

19. Housten WJ, Issacson KG. Orthodontic treatment with removable appliances. 2nd Edition, Bristol, Johan Wright and Sons Limited. 1980; 152-62. 20. Schott T, Goz G. Applicative characteristics of new microelectronic sensors Smart Retainer and Theramon for measuring wear time. J. Orofac. Orthop. 2010; 71(5): 339-347. IVSL. 21. Destang DL, Kerr WJ. Maxillary retention: is longer better? Eur. J. Orthod. 2003; 25; 65-69. 22. Nollet P, Katsaros C, Hof M, Bongaarts C, Semb G, Shaw W, Anne J. Photographs of Study Casts: An Alternative Medium for Rating Dental Arch Relationships in Unilateral Cleft Lip and Palate. Cleft PalateCraniofac. J. 2005; 41(6):646-650. 23. Tibbetts J. The effectiveness of three orthodontic retention systems. A short-term clinical study. Am. J. Orthod. Dentofac. Orthop. 1994; 106: 671-676. 24. Lindauer S, Shoff R. Comparison of essix and Hawley retainers. J Clin Orthod. 1998; 32:95-7. 25. George K, James K, David F, David A, Pratt M. Evaluation of retention protocols among members of the American Association of Orthodontists in the United States. Am. J. Orthod. Dentofac. Orthop. 2011; 140(4):520-526. 26. Keim RG, Gottkieb EL, Nelson AH, Vogels DS. Study of orthodontic diagnosis and treatment procedures, part one: results and trends. J. Clin. Orthod. 2008; 42:625-40. 27. Renkema AM, Sips ET, Bronkhorst E, Kuijpers AM. A survey on orthodontic retention proceduesin the Netherlands. Eur. J. Orthod. 2009; 31: 432-7. 28. Singh P, Grammati S, Krischen R. Orthodontic retention patterns in the United Kingdom. Eur. J. Orthod. 2009; 36: 115-21. 29. Uhde MD. Sadowsky C, Be Gole E. Long term stability of dental relationships after orthodontic treatment. Angle Orthod. J. 1983; 53:240-252. 30. Razdolsky Y, Sadowsky C, Be Gole E. Occlusal contacts following orthodontic treatment: A follow up study. Angle Ortho. J. 1989; 59: 181- 185. 31. Alexander KJ. Treatment and retention for long-term stability. WB Saunders Company, Philadelphia, 1993; p: 115-133. 32. Dincer M, Aslan BI. Effects of thermoplastic retainers on occlusal contacts. Eur. J. Orthod. 2010; 32: 6-10. 33. Renkema AM, Renkema AL, Bronkhorst G, Katsaros C. Long-term effectiveness of canine to canine bonded flexible spiral wire lingual retainers. Am. J. Orthod. Dentofac. Orthop. 2011; 139(5):614-621. 34. Stormann J, Ehmer U. A prospective randomized study of different retainer types. J. Oro. Fac. Orthop. 2002; 63(1):42-50. 35. Lie SF, Ozcan M, Verkerke GJ, Sandham A, Dijkstra PU. Survival of flexible braided and bonded stainless steel lingual retainers. A historic Cohort study. Eur. J. Orthod. 2008; 30(2):199-204. 36. Richard VN. Introduction to dental materials. 3rd Ed Edition, Elsevier Science Limited 2007; p:33. 37. Soderholm KJ, Richards ND, Wear resistance of composites, a solved problem? Gen. Dent. 1998; 46: 256-63. 38. Pratt M, Kluemper G, Lindstrom A. Patient compliance with orthodontic retainers in post-retention phase. Am. J. Orthod. Dentofac. Orthop. 2011; 140:196-201.

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Figure 1: Retainers' materials, A: Clear Advantage Series II durable retainer material, B: Clear Advantage Series I retainer material, C and D: Polymethyl-methacrylate "powder and liquid" and 0.7mm hard stain-less steel wire for fabrication of Hawley retainer, E and F: Fixed lingual bonded retainers "cuspid to cuspid" with assorted sizes bonded with light activated orthodontic bonding system.

Figures 2 A - E: The Clear Advantage Series II thermo-vacuum formed durable invisible retainer.

Figure 3: Clear Advantage Series I thermovacuum formed invisible

Figure 4: Hawley retainer inside a patient's mouth. retainer.

Figure 5: Fixed lingual bonded retainers "cuspid to cuspid"


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Table 1: Descriptive statistics for the clinical performance evaluation of the four types of retainers at the time of insertion using observed numbers and percentage of occurrence.
Clear Advantage Series II Durable invisible retainer N=5 + 1 3 1 (20%) (60%) (20%) 5 0 0 (100%) (0%) (0%) 1 3 1 (20%) (60%) (20%) 4 1 0 (80%) (20%) (0%) 5 0 0 (100%) (0%) (0%) ------5 (100%) 5 (100%) 5 (100%) ------31 (77.5%) ------0 (0%) 0 (0%) 0 (0%) ------7 (7.55%) ------0 (0%) 0 (0%) 0 (0%) ------2 (5%) Clear Advantage Series I standard invisible retainer N=5 + 1 3 1 (20%) (60%) (20%) 5 0 0 (100%) (0%) (0%) 1 3 1 (20%) (60%) (20%) 4 1 0 (80%) (20%) (0%) 5 0 0 (100%) (0%) (0%) ------5 (100%) 5 (100%) 5 (100%) ------31 (77.5%) ------0 (0%) 0 (0%) 0 (0%) ------7 (7.55%) ------0 (0%) 0 (0%) 0 (0%) ------2 (5%) Hawley retainer N=5 + 0 (0%) 0 (0%) 0 (0%) 4 (80%) 1 (20%) ------1 (20%) 0 (0%) 5 (100%) ------11 (27.5%) 1 (20%) 1 (20%) 0 (0%) 1 (20%) 2 (40%) ------1 (20%) 1 (20%) 0 (0%) ------7 (7.5%) 4 (80%) 4 (80%) 5 (100%) 0 (0%) 2 (40%) ------3 (60%) 4 (80%) 0 (0%) ------22 (55%) Fixed bonded lingual retainer N=5 + 0 1 4 (0%) (20%) (80%) 5 0 0 (0%) (0%) (100%) 0 1 4 (0%) (20%) (80%) 5 0 0 (100%) (0%) (0%) 1 1 3 (20%) (20%) (60%) ------1 (20%) 1 (20%) 0 (0%) ------13 (32.5%) ------2 (40%) 3 (60%) 1 (20%) ------9 (22.5%) ------2 (40%) 1 (20%) 4 (80%) ------18 (45%)

Versatility Aesthetic Speech Retention Bad taste and odor Caries risk (Hygienic) Soft tissue irritability Construction Time Chair- side time Failure of retention material Total variables

+ : Superior .

: Acceptable.

- : Inferior.

N: Number of subjects.

Table 2: Descriptive statistics for the clinical performance evaluation of the four types of retainers after three months post- insertion using observed numbers and percentage of occurrence.
Clear Advantage Series II Durable invisible retainer N=5 + 4 1 0 (80%) (20%) (0%) 5 0 0 (100%) (0%) (0%) 3 1 1 (60%) (20%) (20%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) ------5 (100%) 5 (100%) 42 (93.3%) ------0 (0%) 0 (0%) 2 (4.4%) ------0 (0%) 0 (0%) 1 (2.22%) Clear Advantage Series I standard invisible retainer N=5 + 4 1 0 (80%) (20%) (0%) 5 0 0 (100%) (0%) (0%) 3 1 1 (60%) (20%) (20%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) ------1 (20%) 1 (20%) 34 (75.5%) ------4 (80%) 3 (60%) 9 (20%) ------0 (0%) 1 (20%) 2 (4.44%) Hawley retainer N=5 + 1 (20%) 1 (20%) 2 (40%) 3 (60%) 1 (20%) 5 (100%) 1 (20%) ------1 (20%) 2 (40%) 17 (37.7%) 3 (60%) 1 (20%) 2 (40%) 2 (40%) 3 (60%) 0 (0%) 2 (40%) ------4 (80%) 2 (40%) 19 (42.2%) 1 (20%) 3 (60%) 1 (20%) 0 (0%) 1 (20%) 0 (0%) 2 (40%) ------0 (0%) 1 (20%) 9 (20%) Fixed bonded lingual retainer N=5 + 1 1 3 (20%) (20%) (60%) 5 0 0 (100%) (0%) (0%) 0 2 3 (0%) (40%) (60%) 3 1 1 (60%) (20%) (20%) 1 2 2 (20%) (40%) (40%) 0 2 3 (0%) (40%) (60%) 1 3 2 (20%) (60%) (40%) ------1 (20%) 2 (40%) 14 (31.1%) ------1 (20%) 2 (40%) 13 (28.8%) ------3 (60%) 1 (20%) 18 (40%)

Versatility Aesthetic Speech Retention Bad taste and odor Caries risk (Hygienic) Soft tissue irritability Construction Time Chair- side time Failure of retention material Total variables

+ : Superior .

: Acceptable.

- : Inferior.

N: Number of subjects

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Table 3: Descriptive statistics for the clinical performance evaluation of the four types of retainers after six months post- insertion. using observed numbers and percentage of occurrence
Clear Advantage Series II Durable invisible retainer N=5 + 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) 4 1 0 (80%) (20%) (0%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) ------5 (100%) 5 (100%) 44 (97.7%) ------0 (0%) 0 (0%) 1 (2.2%) ------0 (0%) 0 (0%) 0 (0%) Clear Advantage Series I standard invisible retainer N=5 + 2 2 1 (40%) (40%) (20%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) 4 1 0 (80%) (20%) (0%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) ------3 (60%) 1 (20%) 35 (77.7%) ------1 (20%) 2 (40%) 6 (13.3%) ------1 (20%) 2 (40%) 4 (8.8%) Hawley retainer N=5 + 1 (20%) 2 (40%) 4 (80%) 3 (60%) 1 (20%) 5 (100%) 1 (20%) ------1 (20%) 1 (20%) 19 (42.2%) 3 (60%) 2 (40%) 1 (20%) 2 (40%) 3 (60%) 0 (0%) 2 (40%) ------4 (80%) 3 (60%) 19 (42.2%) 1 (20%) 1 (20%) 0 (0%) 0 (0%) 1 (20%) 0 (0%) 2 (40%) ------0 (0%) 1 (20%) 6 (13.3%) Fixed bonded lingual retainer N=5 + 1 (20%) 5 (100%) 0 (0%) 3 (60%) 1 (20%) 0 (0%) 1 (20%) ------0 (0%) 1 (20%) 12 (26.6%) 2 (40%) 0 (0%) 3 (60%) 1 (20%) 2 (40%) 2 (40%) 1 (20%) ------2 (40%) 1 (20%) 15 (33.3%) 2 (40%) 0 (0%) 2 (40%) 1 (20%) 2 (40%) 3 (60%) 2 (40%) ------3 (60%) 3 (60%) 18 (40%)

Versatility Aesthetic Speech Retention Bad taste and odor Caries risk (Hygienic) Soft tissue irritability Construction Time Chair- side time Failure of retention material Total variables

+ : Superior .

: Acceptable.

- : Inferior.

N: Number of subjects

Table 4: Descriptive statistics for the clinical performance evaluation of the four types of retainers after one year post-insertion using observed numbers and percentage of occurrence.
Clear Advantage Series II Durable invisible retainer N=5 + 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) 3 1 1 (60%) (20%) (20%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) ------5 (100%) 5 (100%) 43 (95.5%) ------0 (0%) 0 (0%) 1 (2.2%) ------0 (0%) 0 (0%) 1 (2.2%) Clear Advantage Series I standard invisible retainer N=5 + 2 1 2 (40%) (20%) (40%) 4 1 0 (80%) (20%) (0%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) 3 1 1 (60%) (20%) (20%) 5 0 0 (100%) (0%) (0%) 5 0 0 (100%) (0%) (0%) ------1 (20%) 1 (20%) 31 (68.8%) ------2 (40%) 1 (20%) 6 (13.3%) ------2 (40%) 3 (60%) 8 (17.7%) Hawley retainer N=5 + 1 (20%) 3 (60%) 4 (80%) 1 (20%) 0 (0%) 1 (20%) 1 (20%) ------1 (20%) 1 (20%) 13 (28.8%) 3 (60%) 1 (20%) 1 (20%) 2 (40%) 3 (60%) 4 (80%) 2 (40%) ------3 (60%) 2 (40%) 20 (44.4%) 2 (40%) 1 (20%) 0 (0%) 2 (40%) 2 (40%) 0 (0%) 2 (40%) ------1 (20%) 2 (40%) 12 (26.6%) Fixed bonded lingual retainer N=5 + 2 (40%) 5 (100%) 0 (0%) 3 (60%) 0 (0%) 1 (20%) 0 (0%) ------0 (0%) 0 (0%) 11 (24.4%) 2 (40%) 0 (0%) 3 (60%) 1 (20%) 2 (40%) 1 (20%) 2 (40%) ------1 (20%) 1 (20%) 13 (28.8%) 1 (20%) 0 (0%) 2 (40%) 1 (20%) 3 (60%) 3 (60%) 3 (60%) ------4 (80%) 4 (80%) 21 (46.6%)

Versatility Aesthetic Speech Retention Bad taste and odor Caries risk (Hygienic) Soft tissue irritability Construction Time Chair- side time Failure of retention material Total variables

+ : Superior .

: Acceptable.

- : Inferior.

N: Number of subjects

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Table 5: Comparisons of the total variables of the clinical performance among the four types of retainers at different times using chi square
At time of insertion After 3months post- insertion. After 6 months post- insertion After 1 year ost-insertion Total variables Total variables Total variables Total variables +
_

+
_

+
_

+
_

CII and CI x2 Sig. 0.000 NS 0.000 NS 0.000 NS 0.842 NS 4.454 S 0.332 NS 1.024 NS 3.070 NS 4.000 S 1.944 NS 3.570 NS 5.444 S

CII and HR x2 Sig. 9.521 HS 0.000 NS 16.663 VHS 10.592 HS 13.760 VHS 6.400 S 9.920 HS 16.200 VHS 7.000 HS 16.070 VHS 17.190 VHS 9.306 HS

CII and FR x2 Sig. 13.564 VHS 0.250 NS 17.64 VHS 14.000 VHS 18.066 VHS 15.210 VHS 18.284 VHS 12.250 VHS 18.000 VHS 18.962 VHS 10.284 VHS 18.180 VHS

CI and HR x2 Sig. 9.521 HS 0.000 NS 16.663 VHS 5.666 S 3.570 NS 4.454 NS 4.840 S 3.380 NS 0.818 NS 7.362 HS 7.338 NS 0.800 NS

CI and FR x2 Sig. 13.564 VHS 0.250 NS 17.640 VHS 8.332 HS 0.726 NS 12.800 VHS 11.254 VHS 3.856 NS 8.908 S 9.522 HS 2.578 NS 5.826 S

HR and FR x2 Sig. 0.472 NS 0.250 NS 0.022 NS 0.290 NS 1.124 NS 3.000 NS 1.580 NS 0.470 NS 4.840 S 0.166 NS 1.484 NS 2.454 NS

CII: Clear Advantage Series II Durable invisible retainer. CI: Clear Advantage Series I standard invisible retainer. + : Superior . : Acceptable. - : Inferior.

HR: Hawley retainer. FR: Fixed bonded lingual retainer.


N: Number of subjects.

NS: Non-significant (P>0.05) .

S: Significant ( P< 0.05). HS: Highly significant (P<0.01). VHS: Very highly significant (P < 0.001)
X2: Chi square. Degree of freedom=1.

Table 6: Comparisons of the total time and total variables of the clinical performance among the four types of retainers using chi square
Total time Total variables +
_

CII and CI x2 Sig. 2.890 NS 7.810 S 7.200 NS

CII and HR x2 Sig. 45.440 VHS 38.360 VHS 39.180 VHS

CII and FR x2 Sig. 64.500 VHS 24.920 VHS 68.760 VHS

CI and HR x2 Sig. 26.380 VHS 4.720 NS 17.500 VHS

CI and FR x2 Sig. 42.020 VHS 6.200 NS 42.660 VHS

HR and FR x2 Sig. 2.141 NS 1.940 NS 6.920 NS

CII: Clear Advantage Series II Durable invisible retainer. CI: Clear Advantage Series I standard invisible retainer. + : Superior . : Acceptable. - : Inferior.

HR: Hawley retainer. FR: Fixed bonded lingual retainer.


N: Number of subjects.

NS: Non-significant (P>0.05) .

S: Significant ( P< 0.05). HS: Highly significant (P<0.01). VHS: Very highly significant (P < 0.001)
X2: Chi square. Degree of freedom=3.

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Stimulation of rabbit condyle growth by using pulsed therapeutic ultrasound (A radiographical and histological experimental study)
Mustafa A.Qaisi, B.D.S. (1) Nidhal H. Ghaib, B.D.S., M.Sc. (2)

ABSTRACT
Backgrounds: Many difficulties faced the orthodontic clinician during treatment of class II malocclusion cases in the preadolescence period in which treatment is done by growth modification of condyle , these difficulties are due to the poor cooperation of the patients with the myofunctional appliances. The present research was carried out to evaluate the effect of Low Intensity Pulsed Ultrasound application on mandibular condyle of rabbit radiographically and histologically to evaluate the use of low intensity pulsed ultrasound in condyle growth modification in the treatment of skeletal class II malocclusions in the growth period. Materials and Methods: The sample was 15 New Zealand male rabbits in which Therapeutic Ultrasound was applied to the left condyle (treated group) for 28 days while the right condyle was without ultrasound application (controlled group), After animal sacrifying , the rabbit mandibles were dissected into two hemi mandible, left (treated) and right (control), radiographic image for each hemi mandible was done and three linear measurements were made, (Ramus height, condylar height and mandibular height). Then these hemi mandibles examined histologically including calculating chondrocyte number, osteocyte number, cartilage area calculation and subchondral bone area measurements. Results: the results showed: The increasing of all linear measurements as a result of enhancement of chondrocytes, osteocytes, increase of cartilage area and bone area in the treated group. There is significant correlation between all linear measurements and chondrocyte and cartilage area. Conclusion: low intensity pulsed ultrasound can accelerate condyle cartilage growth. Key Words: therapeutic ultrasound, Low intensity pulsed ultrasound, condyle, growth modifications. (J Bagh Coll Dentistry 2012;24(2):137-143).

INTRODUCTION
Class II malocclusions of skeletal origin are routinely seen in the orthodontic office. Studies of the etiologic factors of Class II malocclusions recognize that most Class II malocclusions are a result of mandibular deficiency and not of maxillary excess (1). Most Class II patients present with retrognathic mandibles and orthognathic maxillae. Patients with mandibular deficiency and Class II malocclusion have a spectrum of esthetic, skeletal, and occlusal characterstics (2,3). However, treating such malocclusions in growing patients by using bitejumping appliances is believed to produce satisfactory improvement in facial esthetics and minimize the need for surgical intervention later. There is evidence that compensatory growth occurs at the tempromandibular joint, and especially the mandibular condyle in response to altered occlusal function in growing animals (4,5). Rabie et al. (6) studied osteogenesis in the glenoid fossa in response to mandibular advancement. They reported that mandibular protrusion resulted in the osteoprogenitor cells being oriented in the direction of the pull of the posterior fibers of the disk (viscoelastic pull) and also resulted in a considerable increase in bone formation in the glenoid fossa.
(1) M.Sc. Student, Department of Orthodontics, Dental College, University of Baghdad. (2) Professor, Department of Orthodontics, Dental College, University of Baghdad.

Ultrasound is a form of mechanical energy that is transmitted through and into biological tissues as an acoustic pressure wave at frequencies above the limit of human hearing, is used widely in medicine as a therapeutic, operative, and diagnostic tool. Therapeutic US, and some operative US, use intensities as high as one to three W/cm2 and can cause considerable heating in living tissues. To take full advantage of this energy absorption, physical therapists often use such levels of US acutely to decrease joint stiffness, reduce pain and muscle spasms, and improve muscle mobility (7,8). Lowintensity pulsed US (LIPUS) has been reported to be effective in angiogenesis enhancement during wound healing. Recently, low-level therapeuticpulsed US was used to enhance bone healing after fracture and after mandibular distraction osteogenesis.(9-11).LIPUS is a type of ultrasound that promotes tissue healing. For such use, US is administered in pulses at lower intensity levels than in physiotherapy (0.5 to 3.0 W/cm2), below 0.1 W/cm2 (12) The mechanisms involved in this process which include mechanotransduction of micromechanical stimuli, will increase local angiogenesis and improved blood supply and aggrecan gene expression (13-15). LIPUS has also been used on growing cartilage. This stimulus has been effective increasing cartilaginous growth potential in primary and secondary

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cartilage (16,17, 18). El-Bialy et al (17,18) applied LIPUS (30 mW/cm2, 1.5 MHz) (Exogen Device) on the temporomandibular joint (TMJ) region of growing rabbits and baboon monkeys for 20 minutes daily. Their results show a significant increase in mandibular cartilaginous growth under LIPUS stimulation, especially under chronic mandibular advancement. The mechanisms that may favor growth could include the same mechanisms involved when bone healing is enhanced with LIPUS.

zirconate titnate transducer and consisted of a 200 microsecond burst of 1 MHz sine that delivered 50 mW/cm2 (model: HEALOSONIC, New Delhi, India) (17,19,20) (Fig1), After four weeks, all waves animals were sacrificed humanly by intravenous injection of 1 mL/kg sodium pentobarbitone, The mandibles were surgically removed, divided at the symphyseal junction into 2 hemi mandibles by straight hand piece (Fig 2).

MATERIALS AND METHODS


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

B C Figure 2: A-Surgical removal of mandible B- Right hemi mandible C- Left hemi mandible

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Figure 3: A- tracing of a hemi mandible showing linearmeasurements taken to evaluate differential mandibular growth changes(17) B- tracing of left hemi mandible by using Auto Cad
All hemi mandibles were radiographed with the X-ray machine, transferred to the laptop by making photographic picture to it using digital camera (Sony Cyber shot) ,then each hemi mandible was traced using (auto cad 2008) program (with control of magnification by rod as standardization).The x ray tracing identified three anatomic points. Three anatomic parameters, two representing anteroposterior mandibular length and one representing mandibular ramus height, were evaluated on the tracing of each hemi mandible .The points and plane and measurements are shown in (Fig3) and are listed below (17): 1. Measuring points Infradentale: most anterior point on alveolar process below the mandibular central incisor. Condylar point: most superior point on the mandibular condylar summit. Angular process: the most posterior contour on the mandibular ramus. 2. Planes and measurements Mandibular plane: a tangent to the inferior border of the mandible. Condylar height: the distance measured between the condylar point and the angular process. Ramus height: the perpendicular distance from condylar point to the mandibular plane. Mandibular height: the distance from condylar point to infradentale. After rabbits were sacrified, the surgically dissected hemi mandibles were embedded in 10% buffered formalin for two weeks for fixation and then decalcified using a solution containing

50% formic acid and 20% sodium citrate. The condylar head and necks were embedded in paraffin, then 5 m thick sections were cut in the sagittal plane with microtome, The tissue sections were mounted on glass slides to be stained with hemotoxylin and eosin, The finished slides were examined using microscope and photomicrographs were taken at 40x power after placing an eye piece with a grid to calibrate the measurements, Then the photomicrographs were transferred to computer software (Auto Cad 2008). A calibration step was performed within the software to get the actual measurements. At the slide photomicrograph of the condylar head, two sections were chosen for histological examination (anterior and posterior sections for each condyle) in way that ensure about all condyle surface is measured, A subchondral rectangular area of 2 mm2 was selected for all slides and subsequent measurements and counts were performed within anterior and posterior sections which are represented by (Fig 4,5):1- Number of chondrocytes. 2- Number of osteocytes. 3- Cartilage thickness area. 4- Bone area. 5- Bone marrow area. The first two were counted manually, while the cartilage area, bone area and marrow area were calculated by the (Auto Cad 2008) software after tracing of it manually. From tracing, the cartilage area was obtained, while for bone area it was obtained by subtraction of marrow area form the whole 2mm2 subchondral area (18).

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

RESULTS
The results included descriptive, comparative and correlation statistics for the anthropometrical and histological variables, the descriptive involved the mean and standard deviation of the three anthropometrical variables and of the four histological variables measured in this study, while for the comparative statistics Students ttests for independent groups were performed, and a significance level of P , .05 was selected. Statistical analysis was done, using SPSS (version 15) software. As shown in (Table 1,2) 1-For the anthropometrical there was a significant increase in the mandibular ramus height condylar height and mandibular height in the US-treated hemi mandibles compared with the untreated hemi mandibles. Enlarged condyles and increased ramal height were clearly observed

in the US-treated sides compared with the nontreated sides (Figure 2 A). 2-For the histological variables there was significant increase in the mean values of chondrocytes number, Osteocytes number, Cartilage thickness area and Bone area in the UStreated condyle Compared with the untreated condyles. For the correlation statistics between histological and anthropometrical variables, there was significant correlation between mandibular height, condylar height and ramus height with chondrocyte numbers and cartilage area in the US treated hemi mandible while the anthropometric parameters did not show significant correlation with histological measurements in the right control side, except there was indirect significant correlation between ramus height and bone area (Table 3, 4).

Table 1: Descriptive & Comparative statistics for saggital jaw linear measurements
Variables Sagittal jaw linear parameters (mm) MH* CH* RH* US treated (Left ) hemi mandibles (N=15) Mean SD 52.06 1.33 18.96 0.48 31.89 0.83 Control (Right) hemi mandibles (N=15) Mean SD 49.97 1.59 17.18 1.15 29.54 1.755 Linear difference (t-test) t D.F P 3.889 28 0.001** 5.498 28 0.000*** 4.696 28 0.000***

MH= Mandibular Height,

CH= Condylar Height,

RH= Ramus Height

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Table 2: Descriptive & Comparative statistics for Histological examination


Histological variables Chondrocyte No. Osteocyte No. Bone area (mm2) Cartilage thickness area (mm2) US treated (Left ) condyle(N=15) Mean SD 473.53 35.49 363 42.75 1.66 0.036 0.21 0.037 Control (Right) condyle (N=15) Mean SD 345.86 58.49 221.73 39.73 1.61 0.04 0.16 0.033 Histology difference (t-test) t D.F p 7.227 28 0.000*** 9.373 28 0.000*** 3.193 28 0.003** 3.763 28 0.001**

Table 3: Correlation analysis between the sagittal jaw linear measurements and Histological measurements of the left hemi mandible
Variabl e MH CH RH r P r P r P Chondrocyt e 0.843*** 0.000 0.565* 0.031 0.692** 0.004 Osteocyt e 0.138 0.625 0.202 0.470 0.406 0.133 Bone area -0.131 0.641 -0.124 0.659 -0.239 0.391 Cartilag e area 0.736** 0.002 0.570* 0.026 0.661** 0.007

Table 4: Correlation analysis between the sagittal jaw linear measurements and Histological measurements of the right hemi mandible
Variable MH CH RH r p-value r p-value r p-value Chondrocyte 0.063 0.823 0.061 0.830 0.247 0.374 Osteocyte 0.450 0.092 0.374 0.169 0.437 0.104 Bone area - 0.497 0.059 - 0.368 0.177 - 0.578* 0.024 Cartilage area 0.101 0.720 - 0.009 0.974 0.175 0.533

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

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occurred due to the fact that ultrasound waves can increase chondrogenesis (26, 27). The greatest increase was in the condylar height measurement and this could be due to the increase of cartilage thickness in vertical dimension more than in anterior and posterior dimension as most of chondrocyte located in the larger upper surface of condyle more than in the anterior and posterior surfaces. The previous study of the effect of pulsed therapeutic ultrasound on rabbit condyle by (17) revealed only the radiographical effect of number in the left condyle may be due to the increase in the vascularization which happened due to the minimum thermal effect of ultrasound that increase blood supply by blood vessels dilations and due to non thermal effect in which Ultrasound waves are able to stimulate mandibular Osteoblast to proliferate and produce angiogenesis related cytokines (28), All of these factors will lead to increase osteocyte nourishment which could increase the osteocyte activity and maturation and formation of other osteocyte .Also it could be as a result to the increase of chondrocyte cells which will pass in the different stages to form osteocytes (29). The significant increase in treated side bone area may be due to the effect of ultrasound which can enhance FGF and VEGF (28), also ultrasound can enhance the process of endochondral ossification (16) .Furthermore Ultrasound can affect Osteogenesis in which Osteoblasts can be stimulated to increase collagen production and increase the production of Prostaglandin E2 (30) .and all of these factors are responsible for bone matrix formation which will lead to increase of bone area. Also, It probably occur

ultrasound on the condyle of rabbit. In the present study, the aim was not to study the radiographic effect alone but to clarify the quantitive histological effect on rabbit condyle if it present. the significant increase in the number of chondrocytes in the US treated side could be due to ultrasound wave effect by which it can stimulate the chondrocyte proliferation and chondrogenesis-associated gene expression(26,27), which lead to increase the mesenchymal cells differentiations to chondroblasts then chondrocytes. While the increase in osteocytes due ultrasound wave ability to change permeability of chondrocytes leading to the increase of intracellular level of Calcium in the chondrocytes and increase in calcium incorporation into differentiating cartilage and bone cell cultures (31) and this can enhance the mineralization of bone. the significant increase in cartilage area in US treated side may be happened due to the increase of extracellular matrix of cartilage by the action of ultrasound waves in the enhancement of FGF which are responsible for fibroblast growth (28) also due to increase in chondrocytes number , and that will lead to increase collagen II, X types production . The presence of significant correlation in left condyle may be due to the increase in the chondrocyte number which will lead to the increase of extracellular matrix formation which results in the increase of cartilage area. The increase in cartilage thickness will effect on the condylar point position and this in the end will affect in a direct relation to all linear measurements because all of these measurement share the same condylar point.

REFERENCES
1- McNamara JA. Components of Class II malocclusion in children 810 years of age. Angle Orthod 1981; 5: 177 202. 2- Epker NB, Fish LC.The surgical-orthodontic correction of mandibular deficiency. Part I. Am J Orthod Dentofacial Orthop 1983; 106: 408 21. 3- Charlier JP, Petrovic A, Herrmann-Stutzmann J. Effects of mandibular hyperpropulsion on the prechondroblastic zone of young rat condyle. Am J Orthod 1969; 55: 714. 4-Charlier JP, Petrovic A, Herrmann-Stutzmann J. Effects of mandibular hyperpropulsion on the prechondroblastic zone of young rat condyle. Am J Orthod 1969; 55: 714. 5-Hinton RJ, McNamara JA Jr. Temporal bone adaptations in response to protrusive function in juvenile and young adult rhesus monkeys (Macaca mulatta). Eur J Orthod 1984; 6: 155-74. 6- Rabie ABM, Zhao Z, Shen G, Hgg EU, Robinson W. Osteogenesis in the glenoid fossa in response to mandibular advancement. Am J Orthod Dentofacial Orthop 2001; 119:390400. 7- Dyson M. Therapeutic applications of ultrasound. [In: Nyborg WL, Ziskin MC, (Eds), Biological Effects of Ultrasound. New York, NY: Churchill Livingstone; 1985.p. 121 33. 8- Maylia E, Nokes LD. The use of ultrasonics in orthopaedicsareview. Technol Health Care 1999; 7:1 28. 9-Young SR, Dyson M. The effect of therapeutic ultrasound on Angiogenesis. Ultrasound Med Biol 1990; 16:261 9. 10- Heckman JD, Ryaby JP, McCabe J, Frey JJ, Kilcoyne RF. Acceleration of tibial fracture-healing by noninvasive, low intensity pulsed ultrasound. J Bone Joint Surg Am 1994; 76:26-34. 11- El-Bialy T, Royston TJ, Magin RL, Evans CA, Zaki AM, Frizzell LA. The effect of pulsed ultrasound on mandibular distraction.Ann Biomed Eng 2002; 30(10):1251 61. 12- Warden S J. A new direction for ultrasound therapy in sports medicine. Sports Med 2003; 33:95107.

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13- Yang, H. , Parvizi H , Wang SJ , Lewallen DG , Kinnick RR, Greenleaf JF, Bolander ME. Exposure to low-intensity ultrasound increases aggrecan gene expression in a rat femur fracture model. J Orthop Res 1996; 14:8029. 14- Rubin C, Turner AS, Bain S, Mallinckdrodt C, McLeod K. Low mechanical signals strengthen long bones. Nature 2001; 412:6034. 15- Rawool N M , Goldberg BB , Forsberg F , Winder AA , Hume E. Power Doppler assessment of vascular changes during fracture treatment with low-intensity ultrasound. J Ultrasound Med 2003; 22:14553. 16- Nolte PA, Klein-Nulend J, Albers GH, Marti RK, Semeins CM, Goei SA. Low-intensity ultrasound stimulates endochondral ossification in vitro. J Orthop Res 2001b; 19:301-7. 17- El-Bialy T, El-Shamy I, Graber TM. Growth Modification of the Rabbit Mandible Using Therapeutic Ultrasound: Is it Possible to Enhance Functional Appliance Results?. Angle Orthod 2003; 73(6): 631-9. 18- El-Bialy T, Hassan A , Albaghdadi T, Fouad HA ,MaimaniA. Growth modification of the mandible with ultrasound in baboons: A preliminary report. Am J Orthod and Dentofacial Orthop 2006;130 (4):6-14. 19-Omran AA. Acceleration of Bone of Distal Radial Fracture with the use of Low Intensity Pulsed Ultra sound. A Board Thesis for the Iraqi Council of Medical Science (ICMS) 2002 20-Warden S J. A new direction for ultrasound therapy in sports medicine. Sports Med 2003; 33:95107. 21- Macari M, Machado CR. Sexual maturity in rabbits defined by the physical and chemical characteristics of the semen. Lab Anim 1978;12: 37- 9. 22- Rawool N M, Goldberg BB, Forsberg F, Winder AA, Hume E. Power Doppler assessment of vascular changes during fracture treatment with low-intensity ultrasound. J Ultrasound Med 2003; 22:14553.

23- Spadaro J, Albanese S. Application of low-intensity ultrasound to growing bone in rats. Ultrasound Med Biol 1998; 24:567 73. 24- Rodrigo O, Mariana Z, Francisco R .Low Intensity Pulsed Ultrasound Stimulation of Condylar Growth in Rats. Angle Orthod 2009; 79(5): 964-70. 25- Tingey TF, Shapiro PA. Selective inhibition of condylar growth in rabbit mandible using intra-articular papain. Am J Orthod Dentofacial Orthop1982; 81(6): 455 64. 26-Wiltink A, Nijweide PJ, Oosterbaan WA, Hekkenberg RT, Helders PJM . Effect of therapeutic ultrasound on endochondral ossification. Ultrasound Med Biol 1995; 21:121-7. 27-Wu CC, Lewallen DG, Bolander ME, Bronk J, Kinnick R, Greenleaf JF . Exposure to low intensity ultrasound stimulates aggrecan gene expression by cultured chondrocytes. Trans Orthop Res Soc 1996; 21:622. 28-Doan N, Reher P, Meghji S, Harris M . In vitro effects of therapeutic ultrasound on cell proliferation, protein synthesis, and cytokine production by human fibroblasts, osteoblasts, and monocytes. J Oral Maxillofac Surg 1999; 57:409-19. 29-Nanci A. Ten Cates Oral Histology: Development, Structre, and Function. 7 ed., Mosby Elsevier, 2008 : 124, 336. 30-Kokubu T, Matsui N, Fujioka H, Tsunoda M, Mizuno K . Lowintensity pulsed ultrasound exposure increases prostaglandinE2 production via the induction of cyclooxygenase-2 mRNA inmouse osteoblasts. Biochem Biophys Res Commun 1999; 256:284-7. 31- Parvizi J, Parpura V, Kinnick RR, Greenleaf JF, Bolander ME. Low intensity ultrasound increases intracellular concentrations of calcium in chondrocytes. Trans Orthop Res Soc 1997; 22:465.

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The relation between W

The relation between W angle and other methods used to assess the sagittal jaw relationship
Sara M. Al-Mashhadany, B.D.S, M.Sc. (1)

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

INTRODUCTION
In orthodontic diagnosis and treatment planning, great importance has been attached to evaluating the sagittal apical base relationship. Both angular and linear measurements have been incorporated into various cephalometric analyses to help the clinician diagnose anteroposterior (AP) discrepancies and establish the most appropriate treatment plan(1). Since Wylies (2) first attempt to describe AP jaw relationship, various other cephalometric parameters have been proposed. Of these parameters, the ANB angle (3) , the Wits appraisal (4), and recently Beta angle (1) are the commonly used parameters. Still, sagittal jaw relationships are difficult to evaluate because of rotations of the jaws during growth, vertical relationships between the jaws and the reference planes, and a lack of validity of the various methods proposed for their evaluation (1, 4-6 ). To determine true apical base relationship independent of the cranial reference planes or dental occlusion, Beta angle was developed(1). The other problem is locating point condylion. The reproducibility of the location of condylion on mouth-closed lateral head films is limited (7- 9) . Most recently introduced sagittal dysplasia indicator is YEN angle (10). But since it measures an angle between line SM and MG, rotation of jaw because of growth or orthodontic treatment can mask true basal dysplasia, similar to ANB angle.
(1) Assistant Lecturer. Department of Orthodontics, College of Dentistry, University of Baghdad

To overcome these existing problems, a measurement was developed and named the W angle. It is a new measurement for assessing the skeletal discrepancy between the maxilla and the mandible in the sagittal plane (Figure 1). It uses three skeletal landmarkspoint S, point M, and point Gto measure an angle that indicates the severity and the type of skeletal dysplasia in the sagittal dimension (11). The purposes of this study were to define the mean value for the W angle in Iraqi adults with a Class I, II, and III skeletal relations and to verify the existence of sexual dimorphism, also to study the correlation between this angle with the other methods used for evaluation of the anteroposterior (AP) jaw relationship.

MATERIALS AND METHODS


To assign samples to the Classes I, II, and III skeletal pattern groups, many files of individuals between 18 and 25 years were screened in the Orthodontic Department of Baghdad University. After the initial selection, all x-rays were traced using AUTO CAD 2007; the ANB and Beta angles and the Wits appraisal were measured by each investigator separately. The mean values of those measurements were calculated. For a patient to be included in the Classes I, II, or III skeletal pattern group, criteria for Beta angle along with one of two (ANB angle and Wits appraisal) had to be met. A skeletal Class I relationship was indicated by an ANB of 24 degrees, a Wits coincidence of AO and BO in females or BO 1 mm ahead of AO in males, and a

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Beta angle of 2735 degrees, Of the 70 patients initially selected class I, only 54 met the criteria to be included after retracing and remeasuring their pretreatment caphalometric x-rays. Therefore, Group I consisted of 54 patients 28 male, 26 female). A skeletal Class II relationship was indicated by an ANB of greater than 4 degrees, a Wits appraisal with AO ahead of BO in females or AO coinciding with or ahead of BO in males, and a Beta angle less than 27 degrees, Of the 58 patients initially chosen as Class II, 40 (18 female, 22 male) met the criteria . The skeletal Class III individuals were characterized by an ANB less than 2 degrees, a Wits BO ahead of AO in females or BO ahead of AO by more than 1 mm in males, and a Beta angle greater than 35 degrees, Of the 65 patients initially chosen as Class III, 58 (28 female, 30 male) met the criteria .

Cephalometric measurements 1. ANB angle: The angle between lines N-A and N-B. It represents the difference between SNA and SNB angles or it may be measured directly as the angle ANB (3, 16). 2. Beta angle: which is the angle between the perpendiculare line from point A to CB line and the AB line (1). 3. The YEN angle: which is the angle between the MG line and the MS line (10). 4. The W angle: This is the angle between the perpendicular line from point M to SG line and the MG line (11). 5. AO-BO(mm): the distance between perpendiculars drawn from point A and point B on to the occlusal plane (4)
Statistical analysis: Collected data were subjected to a computerized statistical analysis using SPSS version 15 (2006) computer program. To summarize the data, means, standard deviations, minimum and maximum of W angle in three groups were calculated, comparison between both genders is done by using independent sample t-test. The oneway analysis of variance (ANOVA) was used followed by LSD to determine whether there was a statistically significant difference between the mean values W angle of the three groups and between each tow groups when there is significant difference, Pearsons correlation coefficient also used to study the correlation between W angle and ANB, YEN angle, BETA angle and Wits appraisal. In the statistical evaluation, the following level of significance is used: Non-significant NS P>0.05 Significant * 0.05 P>0.01 Highly significant ** 0.01 P>0.001 Very highly significant *** P0.0001

Cephalometric Bony Landmarks and lines 1. Point S (Sella): The midpoint of the hypophysial fossa (12). 2. Point N (Nasion): The most anterior point on the nasofrontal suture in the median plane (12). 3. Point A (Subspinale): The deepest midline point on the premaxilla between the Anterior Nasal Spine and Prosthion (13). 4. Point B (Supramentale): The deepest midline point on the mandible between Infradentale and Pogonion (13). 5. Point C (center of the condyle ):found by tracing the head of the condyle and approximately its center ( 1). 6. Point M: midpoint of the premaxilla (14). 7. Point G: centre of the largest circle that is tangent to the internal inferior, anterior, and posterior surfaces of the mandibular symphysis (14, 15) . 8. N- A line: Formed by a line joining Nasion and point A (13). 9. N- B line: Formed by a line joining Nasion and point B (13). 10. Functional occlusal plane: drawn through the cuspal overlap of maxillary first molar and bicuspid (4). 11. Line connecting S and M points. 12. Line connecting M and G points 13. Line connecting S and G points. 14. Line from point M perpendicular to the SG line. 15. Line connecting C and A points. 16. Line connecting C and B points 17. Line connecting A and B points. 18. Line from point A perpendicular to the CB line.
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RESULTS
The descriptive statistics of the five methods used to assess the antero-posterior skeletal relation in male and female groups and their gender difference are shown in (table 1). Table 2 shows the descriptive statistics including mean , standard deviation, standard error ,minimum and maximum for the total sample, also it shows the comparison between the three skeletal relation using f-test followed by LSD test to show the statistical between each two skeletal pattern (table 3). Table 4 reveals the correlation between W angle and ANB, YEN angle, BETA angle and Wits appraisal; Pearsons correlation coefficient used to study the correlation in each skeletal relation.

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

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no statistically significant difference between male and female groups (table 1). Table 4 showed that The W angle had a negative significant relation with ANB in all three classes and with WITS appraisal in class III group, while it had a positive significant relation with BETA and YEN angles in all the three skeletal relations. The geometry of the W angle gives it the advantage to remain relatively stable even when the jaws are rotated or growing vertically. This is a result of rotation of the SG line along with jaw rotation, which carries the perpendicular from point M with it. Because the MG line is also rotating in the same direction, the W angle remains relatively stable. Therefore, measurement of W angle is useful sagittal parameter in skeletal patterns with clockwise or counterclockwise rotation of the jaws as well as during transitional period when vertical facial growth is taking place (figure 2) (11). From this study we can conclude that: 1. The W angle is a diagnostic tool to evaluate the AP jaw relationship more consistently. 2. The mean value for the W angle in Iraqi adults with a Class I, II, and III skeletal relations were 54.8, 49.6 and 59.83 respectively. . 3. There is statistically significant difference in the mean value of W angle among the three skeletal patterns. 4. There is no statistically significant difference between mean W angle values of males and females. 5. The W angle had a negative significant relation with ANB in all three classes and with WITS appraisal in class III group, while it had a positive significant relation with BETA and YEN angles in all the three skeletal relations.

Clinical importance
W angle adds a valuable tool for assessment of AP jaw relationship. Along with other parameters, it should enable better diagnosis and treatment planning for patients.

REFERENCES
1. Baik C Y, Ververidou MA new approach of assessing sagittal discrepancies: the Beta angle. Am J Orthod 2004; 126: 100105. 2. Wylie WL. The assessment of anteroposterior dysplasia. Angle Orthod 1947; 17: 97109. (IVSL)

3. Riedel RA. A cephalometric roentgenographic study of the relation of the maxilla and associated parts to the cranial base in normal and malocclusion of the teeth. Thesis, Northwestern University Dental School, 1948. 4. Jacobson A. The Wits appraisal of jaw disharmony. Am J Orthod 1975; 67: 125138. 5. Moyers R E, Bookstein F L, Guire K E. The concept of pattern in craniofacial growth. Am J Orthod 1979; 76: 136148. 6. Nanda R. Biomechanics and esthetic strategies in clinical orthodontics. Elsevier, St. Louis 2005: pp. 38 73. 7. Adenwalla S T, Kronman J H, Attarzadeh F. Porion and condyle as cephalometric landmarks: an error study. Am J Orthod, 1988; 94: 411415 8. Moore R N, DuBois L M, Boice P A, Igel K A. The accuracy of measuring condylion location. Am J Orthod 1989; 95: 344347. 9. Ghafari J, Baumrind S, Efstratiadis SS. Misinterpreting growth and treatment outcome from serial cephalographs. Clin Orthod Res 1998; 1: 102 106. 10. Neela P K, Mascarenhas R, Husain A. A new sagittal dysplasia indicator: the yen angle. World J Orthod 2009;10: 147151 11. Wasundhara A. Bhad , Subash Nayak, Umal H. Doshi. A new approach of assessing sagittal dysplasia: the W angle. Eur J Orthod 2011; 12. Rakosi T. An atlas and manual of cephalometric radiography. 2nd ed. London: Wolfe medical publications Ltd.; 1982. p. 7, 35, 40, 43, 45, 47-53, 61, 65, 85- 86, 135. 13. Downs WB. Variations in facial relationship: their significance in treatment and prognosis. Am J Orthod 1948; 34(10): 812-40. 14. Nanda R S, Merrill R M. Cephalometric assessment of sagittal relationship between maxilla and mandible. Am J Orthod 1994; 105: 328344 15. Braun S, Kittleson R, Kim K. The G-Axis: a growth vector for the mandible. Angle Orthod 2004; 74: 328 331. (IVSL) 16. Steiner CC. Cephalometrics for you and me. Am J Orthod 1953; 39(10): 729-55. 17. Freeman RS.Adjusting A-N-B anglees to reflect the effect of maxillary position. Angle Orthod 1971; 41; 332-5. (IVSL) 18. Chang HP. Assessment of anteroposterior jawrelationship. Am J Orthod 1987; 92: 117- 22. 19. Walker Gf, Kowalski C. the distribution of the ANBangle in normal individuals. Angle Orthod 1971; 41; 332-5. 20. Kammalamma. Evaluation and correlation of beta angle and wits appraisal in various skeletal malocclusion groups among patient visiting government dental college,Bangalore. A master thesis.Department of orthodontist and dentofacial orthopedics.Rajiv Gandi University of health science, Bangalore, 2009.

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Table 1: Gender difference of the different methods in each of the three skeletal pattern using independent sample t-test.
variable ANB WITS BETA W-angle YEN-angle ANB WITS BETA W-angle YEN-angle ANB WITS BETA W-angle YEN-angle Male mean S.D 3.44 0.9 0.776 1.7 31.68 2.6 55.2 1.5 123.3 2.1 6.955 1.5 4.094 1.8 23.36 4.3 49.59 1.8 116.4 2.1 -0.1 1.6 -3.14 3.1 37.27 4.2 59.9 2.2 129.3 3.2 Female mean S.D 3.069 0.9 -0.29 1.6 31.03 2.8 54.45 1.7 122.1 2.3 7.111 1.6 3.862 2.2 23.72 3.8 49.61 1.8 114.9 2.2 0.214 1.4 -3.35 2.3 37.32 4.2 59.75 2.6 128.7 3.3 Gender difference T-test sig 1.512 0.13 2.416 0.019 0.874 0.38 1.72 0.091 2.077 0.053 -.315 0.754 0.36 0.721 -.276 0.784 -.036 0.972 2.151 0.038 -.799 0.428 0.291 0.772 -.049 0.961 0.235 0.815 0.726 0.471

Class I

Class II

Class III

Table 2: Descriptive and comparative statistics among the three skelatal relations for the total sample.
variables ANB class Class I Class II classIII Class I Class II classIII Class I Class II classIII Class I Class II classIII Class I Class II classIII N 54 40 58 54 40 58 54 40 58 54 40 58 54 40 58 Mean 3.24 7.02 0.05 0.20 3.99 -3.24 31.33 23.53 37.74 54.8 49.6 59.83 122.6 115.7 129 S.D 0.91 1.54 1.49 1.68 2.01 2.75 2.7 4.04 3.68 1.63 1.77 2.41 2.28 2.26 3.24 S.E 0.1 0.2 0.2 0.2 0.3 0.4 0.4 0.6 0.48 0.2 0.3 0.3 0.3 0.4 0.4 Min. 1 5 -4 -3.1 1.01 -12.3 26 13 34 51 44 56 117 112 123 Max. 5 10 3 3.8 9.75 1.3 35 28 49 57 51 66 125 118 136 F-test 326.4 Sig. 0.000

Wits(mm)

125.5

0.000

BETA

198.7

0.000

W_angle

314.5

0.000

Yen_angle

292.9

0.000

Table 3: Comparison between each two different skeletal pattern using LSD .
Variables ANB WITS BETA W-angle YEN-angle Class I-class II Mean difference p-value -3.78 0.000 -3.78 0.000 7.80 0.000 5.19 0.000 6.94 0.000 Class II- class III Mean difference p-value 6.97 0.000 7.22 0.000 -14.21 0.000 -10.22 0.000 -13.3 0.000 Class I-class III Mean difference p-value 3.18 0.000 3.44 0.000 -6.40 0.000 -5.03 0.000 -6.35 0.000

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Table 4: The correlation between the variables in class I,II and III skeletal relations.
Variables ANB class Class I Class II Class III Class I Class II Class III Class I Class II Class III Class I Class II Class III Yen .020 -.522-** -.580-** .044 -.108-.217.154 .070 .302* .733** .579** .788** W- angle -.339-* -.391-* -.680-** -.098-.103-.441-** .362** .381* .564** BETA -.125-.135-.644-** -.301-* -.512-** -.822-** Wit .485** .395* .622**

Wits

BETA

W-angle

**. Correlation is significant at the 0.01 level. *. Correlation is significant at the 0.05 level.

Figure 1: The construction and mode of measuring the W angle.

Figure 2: W angle remains relatively stable even when jaws are rotated.

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A comparative study evaluating the microleakage of different types of restorative materials used in restoration of pulpotomized primary molars
Zainab A. Al-Dahan, B.D.S., M.Sc. (1) Aseel I. Al- Attar, B.D.S., M.Sc. (2) Huda E.A. Al-Rubaee, B.D.S., M.Sc. (2)

ABSTRACT
Background: Possibly the greatest deterrent to the development of an ideal restorative material is the leakage that occurs along the restoration, tooth interface. There is yet no truly adhesive dental material that exactly duplicates physical properties of the tooth structure. This in vitro study was carried out to compare the microleakage of two types of restorative materials used in pediatric dentistry Colored light curing compomer(Twinky star) and nano ceramic restorative material (Ceram.x)) with that of amalgam by measuring their ability to prevent dye penetration. Materials and Methods: Standardized Proximo-occlusal cavity preparations were prepared in 30 extracted sound primary first lower molars. Pulpotomy was performed, and pulpotomy paste filled the pulp chamber with hard setting cement over it all have same occlusal depth. The teeth were then randomly divided into three groups: Group A: filled with Amalgam. Group B: filled with compomer (Twinky star). Group C: filled with nano ceramic (Ceram.x). After that the teeth were stored in distilled water for 30 days at 37 C in an incubator and during the period of storage the teeth were subjected to 300 thermal cycles (10 cycles each day), then sectioned to be examined under the stereo microscope. Results: Data was analyzed using ANOVA test with help of spss soft ware, even though nano ceramic (Ceram. X) showed higher resistance to dye penetration, when compared to compomer (Twinky star and amalgam), there were no significant differences between the three studied groups in their resistance to dye penetration. Conclusion: Depending on the ability to prevent marginal leakage, nano ceramic (ceram.x) and compomer (Twinky star) restorative materials can be used as an alternative to amalgam in restoring pulpotomized primary teeth. Key words: Amalgam, Colored light curing compomer, Twinky star, Nano Ceram.x restorative material, Microleakage. (J Bagh Coll Dentistry 2012;24(2):150-154).

INRODUCTION
Adherence of the restorative material to the cavity walls is one of the most important characteristics for it to be proven as an ideal material because it prevents microleakage(1). Microleakage is defined as the chemically undetectable passage of bacteria, fluids, molecules or ions between the cavity walls and restorative materials. This seepage can cause hypersensitivity of restored tooth, tooth discoloration, recurrent caries, pulpal injury and accelerated deterioration of the restorative material (2) . One of the most important problems today of the restorative dentistry is the failure of restorative material to obtain a complete bond with the enamel and dentin, the formation of microfissures, the penetration of ions, molecules, bacteria and fluids into these fissures and the occurrence of postoperative pain, discoloration at the cavity edges, secondary decays and pulpal inflammations. It has been reported that this phenomenon, referred to as the microleakage, is due to the inadequacy of marginal adaptation between the restoration material and cavity wall.

(1) Professor. Department of Pedodontics and Preventive Dentistry. College of Dentistry. Baghdad University. (2) Assistant lecturer. Department of Orthodontics, Pedodontics and Preventive Dentistry. College of Dentistry. Al-Mustansiria University.

The microleakage is determined today by many in vivo and in vitro techniques such as; staining, which, is the most preferred one(3). Many changes have occurred in development and availability of restorative materials for children. The amalgam has been used for more than 150 years as a restorative material due to its satisfactory clinical characteristics: Low sensitive technique (moisture contamination), satisfactory longevity on primary teeth and diminished microleakage related to corrosive products in tooth/restoration interface. In addition, amalgam is inexpensive and easy to handle (4). Compomers contain glass ionomer cement combined with visible light polymerized resin component. Their excellent physical properties along with fluoride releasing ability, minimal steps in placement and composite like esthetics make them the strongest and most esthetically desirable material. Most restorative materials show varying degrees of marginal leakage because of dimensional changes and lack of adaptability to cavity walls. Microleakage investigation of compomers and their comparison with other materials have compared only a limited number of products but in general have shown adequately sealed restoration margins(5).

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Since nanotechnology was introduced to dentistry, nano composites with filler sizes ranging from 0.01 to 0.04 mm have been developed. Nan composites have many advantages, such as reduced polymerization shrinkage, increased mechanical properties, improved optical characteristics and better gloss retention(6) . CeramX (Dentsply DeTrey, Konstanz, Germany), was developed after introduction of the nanotechnology in dentistry, it's a light cured, radiopaque restorative material for restoration of anterior and posterior teeth. It combines Nanotechnology, with improved organically modified Ceramic particles (7). Nano ceramic (CeramX) contains glass fillers (1.11.5 m) but differs from conventional hybrid composites by two important features: methacrylate-modified silicon dioxide containing nano-filler (10 nm) substitute the microfiller that is typically used in hybrid composites (agglomerates of silicon dioxide particles). According to the manufacturers data, filler concentration is 76% by weight and 57% by volume (6,7). Microleakage performance may be useful for comparative assessment of materials and selection of restorative materials with adequate marginal seal is directly related to the success and longevity of the restorations (2). This study designed to assess the microleakage of different restorative materials: 1. Amalgam. 2. Compomer (Twinky star). 3. Nano ceramic (Ceram.x). Used in restoration of pulpotomized primary molars

MATERIALS AND METHODS


Thirty sound human primary lower first molar teeth free of dental caries extracted for orthodontic purpose (serial extraction) were collected. After extraction; the teeth were cleaned with rubber cup and pumice and scaled by ultrasonic scalar to remove any calculus on the surfaces of the teeth. The teeth stored in distilled water containing thymol crystal 1%, at room temperature (8). The teeth were examined for cracks by the use of magnifying eye lens. Any tooth associated with cracks was excluded and only sound teeth were used (9). Standardized class-II mesio-occlusal cavity was prepared. A tungsten carbide fissure bur No.330 in a turbine hand piece was used with proper water cooling to prepare the cavities (10). The buccolingual width of occlusal preparation was (2.5mm) just enough to allow the entrance of
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no. 6 round bur while the depth of occlusal preparation was (6mm) (measured from pulpal floor to cuspal tip).The buccolingual width of proximal box was( 4mm) and the gingival seat was located (2mm )coronal to CEJ . The length of proximal buccal and lingual walls was (4mm) (measured from gingival seat to cuspal tip (11). Pulpotomy procedure was done for all teeth and floor of pulp filled with pulpotomy paste that is a mixture of one drop of euginol with one drop of tricresol formalin mixed with zinc oxide euginol powder then hard setting cement base of zinc phosphate cement was applied over it, and the occlusal depth of cavity calibrated by reamer with stopper to be the same depth from cusp tips to the cement base for all the teeth about 1.5mm (12). The teeth were divided into three groups of ten teeth each: Group A: was restored with amalgam. Group B: was restored with compomer (Twinky star). Group C: was restored with nano ceramic (Ceram.X). The teeth were then stored in incubator for 30 days in distilled water at 37C each day the teeth were subjected to 10 thermal cycles (300 cycles). This procedure was done to simulate temperature changes in the oral environment which might result in changes in the microspace around the restoration (13). Each tooth was placed in block of cold cure acrylic resin to seal the root apex and furcation area to the area 1mm below the cement enamel junction, then the crown with the block was sealed with two layers of nail varnish to within approximately 1mm of the restoration margins to prevent dye penetration in areas other than the exposed margins (14-17). All the teeth were immersed in 2% methylene blue dye solution at 37C in an incubator for 24 hours (1, 3, 10). Then all the teeth were removed from the dye and washed under running water. Each tooth was then sectioned into two halves and two samples were prepared from each half by sectioning through the center of each restoration, this provide two occlusal and two gingival margins allowing for identification of microleakage through dye penetration. The degree of microleakage was determined by the degree of dye penetration from the margins of the restoration towards the pulp chamber by viewing under a binocular stereo microscope with 10-20 X magnification (1). Under a stereomicroscope the teeth were studied to measure the depth of dye penetration at the two surfaces of the cavity and the score which was higher was given as score to the particular tooth. All the scoring was carried out by a single person

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and as seen clinically in figures (2), (3), (4), (5) and scoring criteria used for the study was as follows (9): 0 = No dye penetration 1 = Dye penetration between the restoration and the tooth into enamel only. 2 = Dye penetration between the restoration and the tooth in the enamel and dentin. 3 = Dye penetration between the restoration and the tooth into the pulp chamber. ANOVA test was used to find any statistical significant differences among the three studied groups.

RESULTS
Table (1) shows the descriptive statistics for the result of methylene blue dye penetration score for the three materials used in present study, this table shows that the higher mean score of dye penetration was for compomer (Twinky star) (1.800.92) followed by amalgam (1.701.16) and the lower mean was found for nano ceramic (Ceram.x) (1.201.03). ANOVA test showed no significant difference among the three groups (F= 0.952 P= 0.398). The percentage of each score is shown in table (2), this table shows that percentage of teeth with absence of dye penetration (score 0) was higher among nano ceramic (Ceram. x) (30%) than both amalgam (20%) and compomer (Twinky star) (10%). On the other hand, concerning maximum score of dye penetration (score 3) the higher percentage of teeth was found for amalgam (30%) followed by compomer (Twinky star) (20%) and lower percentage was found for nano ceramic (Ceram.x) (10%). Figure (1) shows that the percentage of dye penetration score (score2) was higher for teeth filled with compomer (Twinky star) (50%) than both amalgam and nano ceramic (Ceram.x) (30%).

DISCUSSION
Dye penetration is used as a measure to evaluate the performance of the restorative materials. This in vitro study was carried out to evaluate and compare the micro leakage of two new materials in the market and compare them with amalgam (9). The standardized design of a class II cavity preparation and pulpotomy procedure for the sound primary molars used in this study are more commonly representing the main percentages of restorations done for children because most of patient come with severe pain because of pulpal involvement and most of them come with proximal lesions so cavity preparation in proximal boxes extended to the enamel 2mm above
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cementoenamel junction for standardizations for the three restoratives materials to be the same to support the validity of the study design(9,18). Thermal cycling is commonly employed in dye penetration test of dental materials. The regimen of thermal cycling was included in this study because it was commonly used in other previous studies (1, 10, 19). The upper temperature (55C) may be encountered in vivo, but it was perceived that higher temperature is relatively hot and may cause discomfort and this two border of temperature (4C and 55C) simulating changes in temperature in oral cavity (in vivo) and also samples are thermocycled through 30 days as aging process to see effect of time on the restoration (5,20). Many studies had been done on microleakage of class II of posterior permanent teeth restorations and the findings obtained had been assumed to apply to primary teeth, but some evidences suggest significant chemical and morphological differences between primary and permenant dentition This may be of fundamental importance because of morphological differences such as a larger tubular diameter and less mineralization of intertubular dentin areas (21,22). Furthermore, information regarding microleakage in restorations of pulpotomised primary human molars are limited, for these reasons this study was done to estimate microleakage of different restorative materials in pulpotomized primary human molars. The result demonstrates that none of the three filling material was free from dye penetration. Even though, nano ceramic (Ceram.x) showed the least dye penetration with a mean score of (1.201.03), while compomer(Twinky star) demonstrated the greatest dye penetration with mean score of(1.80 0.92), but there were no significant differences between the three studied groups. The result data indicated no significant differences between amalgam group and Compomer(Twinky star) group, this results in agreement with Kitty et al(23), and Mass et al(22) who compared compomer with amalgam restorations in primary teeth, they led to the conclusion that compomer may be recommended as alternative to amalgam in primary molars. Also the results agree with Marks et al(24) who reported a 94% success rate for compomer after 3 years, which is an annual failure rate of 2% and comparable to success rates in permanent teeth. The amalgam used achieved 88% success during the same period. Previous studies have also failed to find significant differences between amalgam and compomers in relation to restoration failures

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despite low failure rates, marginal integrity seems to be different. The findings of this study showed no significant difference between amalgam group and nano ceramic(Ceram.X ) group, this come in agreement with the results of Marcio et al(1) who demonstrate that bonding agents and resin-based materials can exhibit excellent marginal seal for restoration of pulpotomized primary molar when compared with the amalgam. El-Kalla et al (11) demonstrated that bonded resin-based materials increased the fracture resistance of primary teeth restored after pulpotomies. . Comparison between compomer(Twinky star) group and nano ceramic(Ceram.X) group, also indicated no significant difference, this may be due to the fact that both materials have a higher bond strength to enamel and dentin, better mechanical properties , higher filler content and resistance to occlusal load and low polymerization shrinkage (6,7,25). From this in vitro study results, compomer (Twinky star) and nano ceramic (Ceram.X) show no significance difference of dye penetration and resistance to marginal leakage compared with amalgam and can be recommended as a good alternative to amalgam for restoring primary teeth in children.

REFERENCES
1. Marcio G, Kelsey L. Bookmyer, Patricia V, Franklin GG. Microleakage of Restorative Techniques for Pulpotomized Primary Molars J Dent Child 2004; 71: 209-211. 2. Yazici AR, Baseren M, Dayangac B. The effect of current-generation bonding systems on microleakage of resin composite restorations. Quintessence Int 2002; 33:763-769. 3. Yavuz, Izzet, Aydin H. New method for measurement of surface areas of microleakage at the primary teeth by biomolecule characteristics of methilene blue.Biotechnology and Biotechnological Equipment 2005; 19(1):181-187. 4. Cristiane M, Luciana ML. Restorative Treatment on Class I and II Restorations in Primary Molars A Survey of Brazilian Dental Schools. J Clin Pediatr Dent 2005 ; 30(2):175-178. 5. Mali P, Deshpande S, Singh A. Microleakage of restorative materials: An in vitro study. J Indian Soc Pedod Prev Dent 2006; 7 (24):15-18. 6. Schirrmeister JF, Huber K, Hellwig E, Hahan P. Twoyear evalution of a newe nano ceramic restorative material. Clin Oral Investig 2006; 10: 181-186. 7. Manuja N, Pandit IK, Srivastava N, Gugnani N, Nagpal R. Comparative evaluation of shear bond strength of various esthetic restorative materials to dentin. 2011; 29(1): 7-13. 8. Gwinnett AJ, Garcia-Godoy F. Effect of etching time and acid concentration on resin shear bond strength to primary tooth enamel. Am J Dent 1995; 5:237-239.

9. Praphakar A Ra, Madan Mb, Raju O. The marginal seal of a flowable Composite, an injectable resin modified Glass lonomer and a Compomer in primary molars - An in vitro study , J of Ind soci of Pedo and Prev Dent 2003; 21(2):45-48. 10. Cleide CR. Martinohoni, Ricardo, Sousa V. Marginal leakage of polyacid modified composite resin restorations in primary molars. An invitro study.J Appl Oral Sci 2005; 13(2):175-178. 11. El-Kalla IH, Garca-Godoy F. Fracture strength of adhesively restored pulpotomized primary molars. J Dent Child 1999; 66: 238-242. 12. Damle SG.. Text book of pediatric dentistry 2nd edition Darya Ganj, New Delhi; 2004. ch.30 p.295, ch.29 p.279-280. 13. Cavalcante LMA, Pens AR, Amaral CM, Ambrosano GMB, LAF. Influence of polymerization technique on microleakage and microhardness of resin composite restorations. Oper Dent 2003; 28(2): 200-206. 14. Malmstrom H, Schlueter M, Roach T, Moss ME. Effect of thickness of flowable resins on marginal leakage in class II composite restorations. Oper Dent 2002; 27: 373-380. 15. Mgeed M. The effect of adhesive system on marginal leakage of Cl II compound amalgam-composite resin restoration(in vitro study).A Master Thesis. Department of Conservative Dentistry. College of Dentistry.University of Bghdad. 2001. 16. Al-Zubidi M. Assessment of microleakage of different tooth-colored restorative materiasl in primary teeth.(in vitro study).A Master Thesis. Department of Pediatric Dentistry. College of Dentistry .University of Bghdad. 2004. 17. Najman H. Assessment of Microleakage of Different Restorative Materials in Pulpotomized Primary Molars (An in vitro study). A Master Thesis. Department of Pediatric Dentistry. College of Dentistry Medical.University of Hawler. 2008. 18. Ben-Amar A, Liberman R, Nordenberg D, Metzger Z. The effect of retention grooves on gingival marginal leakage in Cl-II posterior composite resin restorations Oral Rehabil 1988; 119: 725-728. 19. Majeed M. The effect of adhesive system on marginal leakage of class II compound amalgam-composite resin restorations (In vitro study). A Master Thesis, Department of Conservative Dentistry, College of Dentistry, University of Baghdad 2001. 20. Yap AUJ and Wee KEC. Effect of cyclic temperature changes on water sorption and solubility of composite restoratives. Oper Dent 2002; 27: 147-153. 21. Sumikawa DA, Marshall GW, Gee L, Marshall SJ. Microstructure of primary tooth dentin. Pediatric Dent 1999; 21: 439-444. 22. Norbert K, Roland D, Frankenberger E. Compomers in restorative therapy of children: a literature review International Journal of Paediatric Dentistry 2007; 17 (1): 2-9. 23. Kitty MH, Stephen HYW. Clinical evaluation of compomer in primary teeth 1-year results JADA1997; 8: 128. 24. Marks LA, Weerheijm KL, Amerongen WE. Dyract versus Tytin Class II restorations in primary molars: 36 months evaluation. Caries Res 1999; 33: 387-392. 25. Mass E, Gordon M, Fuks AB. Assessment of compomer proximal restorations in primary molars: a retrospective study in children. J Dent Child 1999; 66: 93-97.

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Table 1: Dye penetration score (MeanSD) for the three studied groups
Groups Amalgam Twinky Star Ceram.X Mean 1.7 1.8 1.2 SD 1.16 0.92 1.03 F 0.952 d.f 2 Sig 0.398

Table 2: Percentage for score of dye penetration of the three studied groups
Groups Scores 0 1 2 3 Amalgam No. % 2 20 2 20 3 30 3 30 Twinky Star No. % 1 10 2 20 5 50 2 20 Ceram.X No. % 3 30 3 30 3 30 1 10

Figure 1: Comparison of dye penetration among the three studied groups

Figure 2: Digital photograph by stereomicroscope showing score-0 dye penetration (Amalgam)

Figure 3: Digital photograph by stereomicroscope showing score-1 dye penetration (Nano ceramic (Ceram.X))

Figure 4: Digital photograph by stereomicroscope showing score-2 dye penetration (Compomer (Twinky star) group)

Figure 5: Digital photograph by stereomicroscope showing score-3 dye penetration (Compomer (Twinky star) group)

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Oral health status among a group of pregnancy and lactating women in relation to salivary constituents and physical properties (A comparative study)
Zinah M. Taqi Issa, B.D.S. (1) Sulafa K.El-Samarrai, B.D.S., M.Sc., Ph.D. (2)

ABSTRACT
Background: The physiological and hormonal changes during lactating and pregnancy may affect dental and gingival health conditions. The aims of this study were to investigate the occurrence and severity of both dental caries and periodontal diseases among these women in relation to different salivary variables and constituents Materials and Methods: A study group representing 30 lactating mothers whose infants were 4-6 months of age, and 30 pregnant women in the third trimester of pregnancy. Their age was 20-21 years. The control group comprised 30 married non-pregnant nulliparous women. Diagnosis and were recording of dental caries according to the WHO (1987)criteria and GI, PlI according to the Le and Sillness (1964), CI according to the Ramfjord, probing pocket depth according to the Carranza et al, 2002. Stimulated salivary sample was collected according to the Tenovuo &Lagerlof. The average salivary flow rate was measured from total volume, and the pH was determined using the pH meter. Salivary samples were chemically analyzed for the detection of electrolytes (Ca and PO4), and immunoglobulin (IgA), in addition to lysozyme enzyme. Results: The total mean value of dental caries were recorded to be the highest among pregnant group followed by lactating then control with statistically no significant difference (P> 0.05). Concerning the plaque index, gingival index and calculus indices, they were recorded to be highest among pregnant group followed by lactating then control with statistically no significant difference (P> 0.05). Regarding to pH, the control group showed the highest value while the pregnant group exhibited the lower one with highly significant differences was recording between groups P=0.000. The flow rate showed no significant difference between groups. No clinical loss of attachment was seen between the groups. Calcium ions showed a high concentration in saliva of the lactating group compared to the other two groups with highly significant differences P=0.01. Phosphorous ions showed a high concentration in saliva of the lactating group compared to the other two groups with statistically no significant difference (P> 0.05). Regarding salivary lysozyme the highest value was recorded among the pregnant group, while the lowest value was recorded in the control with statistically no significant difference (P >0.05). The same result was seen for salivary IgA but with a statistically significant difference (P <0.05). Conclusion: The severity of dental caries and gingival inflammation were the highest among pregnant group compared to the other two groups. This may related to the changes in the salivary pH and constituent during pregnancy. Keywords: lactating, pregnancy, dental caries, oral health status, salivary pH, salivary flow rate, salivary buffer, calcium, phosphorous, lysozyme enzyme, IgA. (J Bagh Coll Dentistry 2012;24(2):155-159).

INTRODUCTION
Pregnancy and lactation are physiological statuses considered to modify metabolism in animals (1). Both require that numerous physiological adaptations must be made by the maternal organism, to ensure that all the needs of the growing fetus are met and that her own vital functions are maintained (2). Changes occurring during pregnancy in women are well documented but less is known about lactation (3). These changes were reported to have an impact on oral heath as well as dental health. Studies reported an increase in gingival inflammation and caries experience during pregnancy (4-12). Hormonal and physiological changes continue during lactation, however there are limited studies investigating dental and gingival health status among lactating women.
(1) MSc student department of pediatric and preventive dentistry, college of dentistry, University of Baghdad. (2) Professor, department of pediatric and preventive dentistry, college of dentistry, University of Baghdad.

Other studies were conducted investigating changes in salivary variables (flow rate, pH and buffer capacity) as well as salivary constituents as electrolytes, immunoglobulin and hormonal changes during pregnancy. These were correlated with oral and dental health, and a controversy in the result was noticed (4, 11, 13-15). On other hand only one Iraqi study was able to be found regarding salivary calcium during lactation (16). The aim of this study was to investigate oral health status in relating to salivary variables and constituents among lactating and pregnant groups.

MATERIALS AND MATHODS


The sample taken in this study was 90 women divided into three groups; each group is composed of 30 volunteers; a first study group representing lactating mothers whose infants were 4-6 months of age and the second group was pregnant women in the third trimester of pregnancy. Each of them were 20-21 years old primiparous mothers. The

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control group comprised 30 married non-pregnant nulliparous women; these women were age matched with the study group. Subjects should be without any medical disease and no history of smoking. Dental examination was done after collection of salivary sample. The examination of dental caries was conducted according to the criteria of WHO(17). Oral examination was carried out using plane mouth mirror and dental explorer. The collection of stimulated salivary samples was performed following assesment of dental plaque under standard condition following instruction cited by (18). Each individual was asked to chew a piece of Arabic gum (0.5-0.7 gm) for one minute all saliva was removed by expectoration, chewing was then continued for five minutes with the same piece of gum and saliva collected in a sterile screw capped bottle. Salivary pH was measured using an electronic pH meter and flow rate of saliva was expressed as milliliter per minute (ml / min). The salivary samples were then taken to the laboratory for biochemical analysis. Samples were centrifuged at 4000 rpm for 30 minutes; the clear

supernatant was separated by micropipette and was divided into three portions, stored at (-20C) in a deep freeze till being assessed in the Teaching Laboratories of the Medical City Hospital. Data process and analysis were done by using the Statistical Package for Social Sciences (SPSS version 17). Statistical tested used in this study were; analysis of variance (ANOVA), least significant difference (LSD) test, were used to test the difference between variable, Paersons correlation coefficient were all applied to see if there is any correlation between variables. The confidence limit was accepted at 95% (P < 0.05).

RESULTS
Table 1 demonstrates the mean values and standard deviations of caries- experience according to DMFS/DMFT indices among study and control groups. Results showed that there no statistically significant differences between three groups.

Table 1: Caries Experience (Mean and Standard Deviation) among Study and Control Groups.
Groups Lactating Pregnant Control DS MeanSD 1.332.83 1.833.04 1.102.95 MS MeanSD 1.374.25 1.603.96 0.831.89 FS MeanSD 0.530.99 0.801.44 0.270.63 DMFS MeanSD 3.236.19 4.235.94 2.203.71 DMFT MeanSD 1.0602.12 1.702.10 0.9961.35

Table 2 reveals the mean values of plaque, calculus and gingival indices among study and control groups. For the three indices statistically no significant differences were recoreding between the three groups (P >0.05). The correlations coefficients between plaque and calculus indices with the gingival index among the three groups showed a positive statistically significant correlation between plaque index and gingival index in the control and lactating groups (r = 0.456, P <0.05). No correlation was seen between gingival index and plaque index in the group of pregnancy. Results also showed that gingival index is not correlated with calculus index in all groups. Table 3 presents pH values, rates of secretions of stimulated saliva and buffer capacity among study and control groups. Concerning pH, the control group showed the highest value while the pregnant group exhibited the lower one; a statistically significant difference was noticed between the three groups. When the least significant differences test was applied the statistically highly significant differences were present in pH value between the pregnant group with the control, and the lactating group with
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control. Salivary flow rate mean value was the highest in the pregnant group compared to other groups, statistically no significant difference was noticed between the three groups (P >0.05). Regarding the buffer capacity, results showed a highest value among the control group with statistically highly significant differences between them. In general no significant correlations were recorded between caries-experience with salivary variables among the three groups, except for the salivary flow rate; a negative significant correlation with DMFS in group of lactating women was noticed (r=-0.384 P=0.036). Also no significant correlations were recorded between plaque and gingival indices in addition to calculus index with salivary variables among the three groups, except for the salivary pH; a positive significant correlation was seen with gingival index (r=0.363, P= 0.048) and a negative significant correlation was seen in flow rate with calculus index in the lactating group (r=-0.459, P= 0.011). Table 4 shows the mean concentration values of salivary electrolytes (calcium and phosphorous), salivary lysozyme and IgA and

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standard deviation among different groups. Calcium ions showed a high concentration in saliva of the lactating group compared to the other two groups, difference between the study and control groups was statistically highly significant (F=80.080, P=0.01) . Phosphorous ions showed the highest concentration in saliva of the lactating group compared to the other two groups, difference between the three groups was

statistically not significant (F=0.355, P=0.702). Regarding salivary lysozyme the highest value was recorded among the pregnant group, while the lowest value was recorded in the control with statistically no significant difference (P >0.05). The same result was seen for salivary IgA but with a statistically significant difference (P <0.05).

Table 2: Plaque Index, Gingival Index, and Calculus Index (Mean and Standard Deviation) among Study and Control Groups
Groups Lactating Pregnant Control PlI MeanSD 1.230 0.28 1.135 0.29 1.195 0.37 GI MeanSD 1.276 0.28 1.340 0.31 1.252 0.31 CI MeanSD 0.009 0.02 0.020 0.06 0.003 0.01

Table 3: Salivary (pH), Flow Rate and Buffer effect (Mean and Standard Deviation) among study and control groups.
Groups Lactating Pregnant Control pH MeanSD 7.252* 0.363 7.000 0.358 7.420 0.304 Flow rate ml/min MeanSD 0.9930.321 1.2301.003 0.900 0.303 Buffer capacity MeanSD 5.163** 0.961 4.315 0.452 6.835 3.073

Table 4: Salivary Electrolytes (Calcium & Phosphorous), salivary lysozyme and IgA (Mean and Standard Deviation) among Study and Control Groups.
Group Lactating Pregnant Control Statistical test Ca ion mg/dl Mean SD 7.0783.484 1.1320.085 1.652 0.202 F=80.08 P=0.000 PO4 mg/dl Mean SD 6.0433.321 5.5122.388 6.0192.485 F=0.355 P=0.702 Salivary Lysozyme (ng/ml) Mean SD 27.3018.093 29.8623.431 26.5416.155 F=0.239 P=0.788 Salivary IgA (mg/dl) Mean SD 25.757.935 36.2222.721 25.291.002 F= 5.925 P=0.004

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

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The soft and hard tissues of the oral cavity are under the protection of both non-specific and specific immune systems. Their function is to limit the microbial colonization of oral surfaces and to prevent the penetration of noxious substances through the surfaces and ensuing damage to the underlying tissues (23). In this study salivary IgA was the highest in the pregnant group and the lowest in the control group with a statistically highly significant difference. Secretion and synthesis of IgA may be affected by stress, physical exercises, medications, menstrual cycle, and pregnancy (24). The hormonal changes during pregnancy may have altered the IgA levels because the production of estrogen and progesterone increases gradually until the eighth month of pregnancy and both hormones modulate the immune system during the gestational period (15) . The higher levels of salivary IgA may provide greater protection against infections due to gingival inflammation during pregnancy. Lysozyme co-operates with other antibacterial systems (e.g. IgA) and causes bacteria aggregation (25). Salivary pH and buffering capacity reach their lowest values during the third trimester of pregnancy, thus increasing the risk of caries, which is further increased by enhanced levels of salivary streptococcus mutans therefore this increase may lead to increase in lysozyme. On the other hand, elevated lysozyme content can increase the clearance of bacteria from oral cavity, thus playing a protective role. In addition the increase in salivary lysozyme may be due to the increased salivary flow rate during pregnancy (26). The present study reported a positive correlation between plaque and gingival indices which was significant in the lactating and control groups, but not in the pregnant group, thus, dental plaque may not be the only etiological factor for gingivitis among pregnant group compared to the other two groups. During pregnancy, the action of the hormones on the periodontal cells involves altering the effectiveness of the epithelial barrier to bacterial insult, and affecting the collagen maintenance and repair increasing the risk of gingival inflammation (28). Results revealed that all women examined had gingival pocket not higher than 3mm, and no clinical loss of attachment. Periodontitis requires a chronic inflammatory state of the gingiva lasting longer than those months of pregnancy (15). Results revealed that the changes in salivary variables and composition may have an impact on the dental and gingival health status of both the pregnant and lactating groups. Thus, it is recommended that these two groups to receive a special program to

control and prevent dental caries as well as periodontal diseases.

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