Introduction

Normal occlusion and malocclusion are two opposite side of a coin. However, there are some cases where it is difficult to differentiate normal occlusion from malocclusion. Normally it is very easy to notice malocclusion in patients but in some cases other features make it difficult to identify as malocclusion. Before we discuss the present article it would be logical to focus a little on different aspect of normal occlusion and malocclusion for easy understanding of the readers.

1. Dr. Mohammed Saifuddin¹
   BDS (Dhaka), PGT (Japan), PhD (Japan) Associate Professor and Head Dept. of Orthodontics, Pioneer Dental College & Hospital, Dhaka.
2. Dr. Shahana Begum²
   BDS (Dhaka), PhD (Japan) Associate Professor Dept. of Oral & Maxillofacial Surgery, Pioneer Dental College & Hospital, Dhaka.

• Address of Correspondence
• Dr. Mohammed Saifuddin¹
  BDS (Dhaka), PGT (Japan), PhD (Japan) Associate Professor and Head Dept. of Orthodontics, Pioneer Dental College & Hospital, Dhaka.

What is Normal Occlusion?

It is well known among the dentists that Angle’s Class I molar relationship along with class I canine and incisor relationship with 2-3 mm overjet and overbite should be considered as normal or ideal occlusion. But there are some patients who have all class I dental features but some minor irregularities push them into malocclusion group. These types of cases sometimes put the dentists in dilemma to decide whether the patients need treatment or not. What is Malocclusion? An unacceptable deviation- esthetically and/or functionally from the ideal occlusion is called Malocclusion. (Fig:1a). However, the term “Unacceptable deviation” sometimes used to make the dentists confused to differentiate the malocclusion from that of normal occlusion as there was no such easy method to diagnose this type of case with out the diagnostic tools like model casts, orthopentamogram and lateral cephalogram. But in practice sometimes it becomes very important to justify the case on the spot only by the visual appearance of the patient1. Therefore, it was inevitable that an easy method should be available in practice to find out who really needs orthodontic treatment.

Problems those lead the patients to seek for the orthodontic treatment: Protruded, irregular or maloccluded teeth can cause three types of problems: 1. Psychosocial problems: Patients suffer from inferiority complex. Patients become socially handicap. They face negative status in the schools and in the employability. They even face negative status during competition for a mate. And these problems are not “just cosmetic”. 2. Oral functions: A severe malocclusion may compromise all aspects of oral functions. Adults with severe malocclusion routinely report difficulty in chewing, which after treatment are largely corrected. It can be difficult or impossible to produce certain sounds and effective speech therapy may need some orthodontic treatment. Relationship of malocclusion and adaptive function to Temporo-mandibular dysfunctions (TMDs) manifested as pain in and around the TM joint take place in many patients.1,33 3. Relationship to injury and dental diseases: Malocclusion has a deep relation to different dental injuries and diseases. Protruded maxillary incisors can increase the likelihood of injury in class II cases resulting in fracture or devitalisation of pulp. Extreme overbite leads the lower incisors to contact the palate and can cause significant tissue damages and ultimately loss of upper incisors in few patients. Extreme wear of incisors also occur in excessive overbite cases. Malocclusion can contribute to both dental decay and periodontal disease by making harder to care for the teeth properly or by causing occlusal trauma. How to diagnose the treatment need? Severity of a malocclusion correlates with need for treatment. Several indices for scoring the deviation of teeth from the normal as indicator of orthodontic treatment need were proposed. Among them scoring system by Shaw and co-workers the “Index of Treatment Need” (IOTN) seems effective. IOTN places patients in five grades from “No need for Treatment” to “Treatment Need”. The index has a dental health component derived from occlusion and alignment and an esthetic component derived from comparison of dental appearance to some standard photographs. This can help the dentists to find out whether the patients need orthodontic treatment. These are as follows: IOTN: Index Of Treatment Need.

Grade 5 (Extreme/ Need Treatment) Fig:1b, 1c

• Increased Overjet (OJ) > 9mm.
• Reverse OJ> 3.5 mm with masticatory / speech defects.
• Cleft lip and palate defects and craniofacial anomalies.

• Increased OJ > 6 mm but ≤ 9 mm.
• Increased and complete OB with gingival or palatal trauma.
• Reverse OJ > 3.5 mm with no masticatory / speech defects.
• Anterior or lateral open bite > 4 mm.
• Anterior or posterior cross bite.

• Increased OJ > 3.5 mm but ≤ 6 mm with incompetent lips.
• Increased and complete OB on gingiva / palate but no trauma.
• Reverse OJ > 1 mm but ≤ 3.5 mm.
• Anterior or posterior cross bite.
• Anterior or lateral open bite > 2 mm but ≤ 4 mm.

• Increased OJ >3.5 mm but ≤ 6 mm with competent lips.
• Increased OB ≥ 3.5 mm without gingival contact.
• Reverse OJ > 0 mm but ≤ 1 mm.
• Pre-normal or post normal occlusion with no other anomalies.

Extremely minor malocclusions including contact point displacements less than 1 mm. Conclusion: In the present article an effort was made for easy and handy “On the spot diagnosis” of the patients who need orthodontic treatment on the basis of some series of photographs. It might be expected that this widely used method would be proved useful for the dentists in the dental clinics and hospitals in remote areas of our country where the diagnostic tools are not readily available for early diagnosis and proper intervention. Therefore, proper utilization of this easy method would help a great number of orthodontic patients to be diagnosed early to receive the proper treatment thereafter.

1. Millett D, Welbury R. Classification to assess treatment need. In: Orthodontics and Paediatric Dentistry. 1st ed. London : Churchill Living stone, A Harcourt Publisher Limited, 2000: P. 7-10.
2. Proffit WR, Fields HW. Malocclusion and Dentofacial Deformity in Contemporary society. In: Contemporary Orthodontics. 3rd ed. St. Louis, Missssouri: Mosby, Inc. A

1. Shaw WC: The influence of children’s dentofacial appearance on their social attractiveness as judged by peers and lay adults. Am J Orthod 1981; 79: 399-415.
2. Shaw WC, Rees G, Dawe M, Charles CR: The influence of dentofacial appearance on the social attractiveness of young adults. Am J Orthod 1985; 87: 21-26.

Introduction

After loss of natural teeth, provision of prosthodontic services almost becomes a necessity in the present day living. Prosthodontists who treat a large number of edentulous patients realize that there are a number of patients who cannot be satisfied aesthetically, functionally or both. For these patients, even a more objective selection criteria will be unsuccessful. However, for the majority of edentulous patients, a simple objective technique involving anatomical measurements would provide at least a starting point for tooth selection.

1. Dr. Kamrun Nahar Naly
   Assistant Professor, Department of Science of Dental Materials, Pioneer Dental College, Dhaka, Bangladesh.
2. Dr. Hasibush Shahid
   Lecturer, Department of Science of Dental Materials, Pioneer Dental College, Dhaka, Bangladesh.
3. Dr. Jamil Ahsan Ansary
   Assistant Professor & Head , Department of Science of Dental Materials, Pioneer Dental College, Dhaka, Bangladesh.

• Address of Correspondence
• Dr. Kamrun Nahar Naly
  Assistant Professor, Department of Science of Dental Materials, Pioneer Dental College, Dhaka, Bangladesh.

What is Normal Occlusion?

Prosthesis cannot be an exact substitute of natural teeth, if prepared properly based upon some measurable parameters then they are not only functionally stable but also aesthetically and biologically viable.12 To improve aesthetic and functional outcomes with respect to patients’ requirements and desires, it is necessary to place the maxillary central incisors in complete denture in the same position as natural teeth, relative to incisive papilla.1 The earlier researchers have described different arch form as square, tapered and ovoid.16 Combinations of these forms are well recognized in prosthodontics.5 The assessment of arch forms has been done by their geometric description.7, 8, 13-15,16 There is a distinct relationship between face form and arch form, especially as related to the upper arch.6 In absence of pre-extraction records, the incisive papilla is an important anatomical landmark that can be used as an aid for anterior teeth positioning.1 It is an immobile structure and usually does not shift in adult life.2,12 The researcher used maxillary central incisor to incisive papilla distance as a biometric guide.3,4,12 With gross resorption of the buccal plate after tooth extraction, the papilla may appear to be on the crest of the alveolar ridge and in cases of more severe resorption it would appear to be in front of the ridge.

The midpoint of incisive papilla is more commonly used as the reference point, although the posterior part of the incisive papilla is more stable, as it undergoes least change after teeth have been extracted.1,2 This investigation was done to determine whether measurement of central incisor to incisive papilla distance in dentate individuals can provide some meaningful guidelines for the maxillary anterior teeth arrangement while dealing with prosthodontic patients having similar face forms.

Objective

To find out the distance between incisive papilla and maxillary central incisors in a tapered face form and a ovoid face form as a guide to anterior teeth arrangement for complete denture.

Materials and methods

The study was designed as cross sectional and observational. The study was done in department of prosthodontics, Bangabandhu Sheikh Mujib Medical University (BSMMU) From March’ 2014 to August’ 2014. Patients attended in the department of prosthodontics in BSMMU for the treatment of the lower arch. It was a non-probability convenience sampling method. 61 Patients (male and female) of 20 -40 years age range were selected with dentate maxillae. Intact maxillary dental arch., periodontally sound maxillary anterior teeth, class I arch relationship, angle’s class I occlusal relationship were in inclusion criteria. Patients with supernumerary tooth erupted in maxillary arch, maxillary midline diastema, any degree of crowding in maxillary dentition, visible attrition involving incisal edge, rotation of maxillary anterior teeth, history of previous orthodontic treatment, any soft tissue lesion involving incisive papilla, no history of surgical procedure in maxillary arch were in exclusion criteria. Digital verniaer scale, calibrated transparent protector, surveyor-Marathon-103, base former, lead pencil, rubber bowl, spatula and impression tray were the equipments. Alginate, die stone and sticky wax were used as materials. Data are expressed as mean, ± standard deviation. Statistical analysis was done by ANOVA. P < 0.05 level of significance was selected for all analyses.

Procedures

The patient was selected by thorough medical and dental history followed by selection criteria of this study.

The patient was seated on the well equipped dental chair in free head position. Face form was assessed. Human face form was classified into 3 types: square, tapering and ovoid. Here I selected the face form of ovoid and tapering. In order to determine what type an individual belongs, we imagine two lines one on either side of the face, running about 2.5 cm in front of the tragus of the ear and through the angle of the jaw. if they diverge at the chin the type is ovoid; if they converge towards the chin the type is tapering. After that the impression was taken with high viscosity alginate impression material by using correct powder/liquid ratios, and proper mixing technique as provided by the manufacturer. After taking the impression, it was rinsed in running water. Sterilization of the impression was done. The cast was poured with die stone within 15 minutes after making the impression. Standardization was done by making the base of the cast by using base former. The cast was retrieved from the base former after 45 minutes. Arch form was assessed on the cast. The central incisors in the ovoid arch are forward of the canines in a position between that of square and tapering arch, have a broader effect that should harmonize with an ovoid face. The central incisors in the tapering arch are a greater distance forward from the canines than any other arch. This is usually in harmony with a tapering face. Incisive papilla was first identified and then the boundaries were marked by using a hard lead pencil. Cast was secured to a cast surveyor. The horizontal distance between vertical pin of the surveyor and the embrasure between the maxillary central incisors was measured by placing the protector in such a way that it’s 90 degree marking was almost superimposing the vertical pin of the surveyor, which at this stage was touching the posterior border of incisive papilla. After securing protector in that manner sticky wax was applied to protector and the vertical pin, to stop any unwanted movement. Horizontal distance will be measured on the calibrated transparent protector by using caliper device placing at one end which will coincide with the vertical pin and the other end of the incisal edges.

Results

Total 61 males and females with 20-40 years old patients were observed for the result of taper and ovoid face form

In table-3 showed, central incisor to incisive papilla distance of all patients (n=100) was shown in mean. Among the patients tapered face form patients had mean distance of incisive papilla to central incisor 12.49 mm with SD 0.44 , ovoid face form patients had mean distance of incisive papilla to maxillary central incisor 11.39 with SD 0.69. ANOVA was done for statistical analysis. P value < 0.05 was significant.

Discussion

This study was conducted on 61 dentate individuals (n=61) having different face forms (tapered, and ovoid). After sample selection, impressions were made for upper arches and the resultant casts were standardized. Measurement on the casts were recorded for posterior border of the incisive papilla and embrasure between upper central incisors distance, after securing the casts on the dental surveyor. Same methodology was also used in Majid et al10 study, but they measured the distance from posterior border of incisive papilla to mesial edge of maxillary central incisors. In G. C. Lau9 et al study, a photographic technique was used to measure the distance from the labial surface of central incisors to posterior border of incisive papilla. So there is little difference between the measurements of distance in these studies as the reference points on the central incisors differs. Among the patients (n=61) it was observed that tapered face form was the commonest type of face forms found in both males and females (85.25%). This seems converse to the results of earlier studies conducted by Majid et al, Kook et al and Nakatsuka et al. In Majid et al10 study, the most frequent arch form was that of ovoid arches where as Kook et al11 Ovoid face forms were seen in (9%) males and females. Fig-1 shows that patients participated in the study were within the age range of 20-40 years. Among the patients (n=61), 70% were in the age group of 20-30 years and 30% were in the age group of 31-40 years Previously the studies conducted on central incisor to incisive papilla distance were also considered of the same age group, 8-10 the

reason was anatomical stability and integrity of natural dentition within this age group.10 According to table-1, table-2 and table-3 of the present study, mean distance of central incisor to incisive papilla in males with tapered face forms were (12.59±o.48) and in case of female it was (12.35±0.34). In ovoid face forms mean was (11.50±0.79) for male and (11.25± 0.6) for female. Majid et al found in their study that mean central incisor to incisive papilla distance was (11.2 mm vs 10.5mm) in ovoid arch form males and females.12 According to G. C. Lau et al study the distances from posterior border of incisive papilla to labial surface of upper central incisor in subjects with class1, class 2 and class 3 incisal malocclusion were 12.65mm, 12.45mm and 13.18mm.9 The result of this study revealed that there was a statistically significant difference in central incisor to incisive papilla distance in patients with tapered and square face forms (p < 0.05). Majid et al found statistically significant difference in central incisor to incisive papilla distance in case of tapered and ovoid arch form, they found no significant difference in square arch form.10 G.C.Lau et al found differences in incisive papilla to central incisor distances among class 1, class 2 and class 3 malocclusion were not statistically significant.9 In all of these studies measurements were obtained from a slightly different reference point on the central incisor

Conclusion

With the limitation of this study it can be concluded that:

• Mean value of central incisor to incisive papilla distance for tapered face formed male was 12.59 mm and 12.35 mm for female, 11.25 mm for ovoid face-formed male and female.
• Majority of patients (85.25%) had a tapered type of face form.
• Central incisor to incisive papilla distance differs significantly in tapered and ovoid face formed patients

reason was anatomical stability and integrity of natural dentition within this age group.10 According to table-1, table-2 and table-3 of the present study, mean distance of central incisor to incisive papilla in males with tapered face forms were (12.59±o.48) and in case of female it was (12.35±0.34). In ovoid face forms mean was (11.50±0.79) for male and (11.25± 0.6) for female. Majid et al found in their study that mean central incisor to incisive papilla distance was (11.2 mm vs 10.5mm) in ovoid arch form males and females.12 According to G. C. Lau et al study the distances from posterior border of incisive papilla to labial surface of upper central incisor in subjects with class1, class 2 and class 3 incisal malocclusion were 12.65mm, 12.45mm and 13.18mm.9 The result of this study revealed that there was a statistically significant difference in central incisor to incisive papilla distance in patients with tapered and square face forms (p < 0.05). Majid et al found statistically significant difference in central incisor to incisive papilla distance in case of tapered and ovoid arch form, they found no significant difference in square arch form.10 G.C.Lau et al found differences in incisive papilla to central incisor distances among class 1, class 2 and class 3 malocclusion were not statistically significant.9 In all of these studies measurements were obtained from a slightly different reference point on the central incisor

Conclusion

With the limitation of this study it can be concluded that:

• Mean value of central incisor to incisive papilla distance for tapered face formed male was 12.59 mm and 12.35 mm for female, 11.25 mm for ovoid face-formed male and female.
• Majority of patients (85.25%) had a tapered type of face form.
• Central incisor to incisive papilla distance differs significantly in tapered and ovoid face formed patients

1. Zakiah M, Isa and Laith M, Abdul Hadi. A Relationship of Maxillary Incisors in Complete Dentures to the Incisive Papilla. J Oral Science 2012; 54(2): 159-63.
2. Ehrlich J, Gazid E. Relationship of the Maxillary Central Incisors and Canines to the Incisive Papilla. J Oral Rehabil 1975; 2: 309-12.
3. Ortman HR, Tsao DH. Relationship of the Incisive Papilla to Maxillary Central Incisors. J Prosthet Dent 1979; 42: 492-96.
4. Schiffman P. Relationship of the Maxillary Canines to the Incisive Papilla. J Prosthet Dent 1964; 14: 469-72.
5. Pound E. Applying Harmony in Selecting and Arranging Teeth. Dent Clin North Am; 241-258.
6. Nelson AA. The Aesthetic Triangle in the Arrangement of Teeth. J Nat Dent Assoc 1922; 9:392-401.
7. Roraff AR. Arranging Artificial Teeth According to Anatomic Landmarks. J Prosthet Dent 1977; 38: 120-30.
8. Mersel A, Ehrlich J. Connection Between Incisive Papilla, Central Incisor and RugaeCanina. Quintessence Int 1981; 12: 1327-9.
9. Lau GC, Clark RF. The Relationship of the Incisive Papilla to the Central Incisors and Canine Teeth in Southern Chinese. J Prosthet Dent 1993; 70: 86-93.
10. Majid Zia, Azad Ali Azad, Salman Ahmed. Comparison of Distance Between Maxillary Central Incisors and Incisive Papilla in Dentate Individuals with Different Arch Forms. J Ayub Med Coll Abbottabad 2009;21 (4):125-128

Introduction

Introduction While the eyes may be the window to the soul, our mouth is a window to our body’s health” The state of your oral health can offer lots of clues about your overall health. Oral health may be defined as a standard of health of the oral and related tissues which enables an individual to eat, speak and socialize without active disease, discomfort or embarrassment and which contributes to general wellbeing.1

1. Dr. Shamim Ahmed
   Consultant, Tamanna Dental Zone, Dhaka email: drshamimahmed78@gmail.com
2. Dr. Tasnova Tamanna
   Chief Consultant, Tamanna Dental Zone, Dhaka

• Address of Correspondence
• Dr. Shamim Ahmed
  Consultant, Tamanna Dental Zone, Dhaka email: drshamimahmed78@gmail.com

Most oral diseases, like most chronic pathologies in general, are directly related to lifestyle. Oral disease can be considered a public health problem due to its high prevalence and significant social impact. Chronic oral disease typically leads to tooth loss, and in some cases has physical, emotional and economic impacts, physical appearance and dies are often worsened, and the patterns of daily life and social relations are often negatively affected. These impacts lead in turn to reduced welfare and quality of life. To minimize the senegative impacts of chronic oral disease, there is thus a cleared to reduce harmful oral health habits. Such are duction can be achieved through appropriate health education programs.2 In modern dentistry, “prevention” receives special attention and precedes treatment. Prevention is easier and more economical. Now a days, in advanced societies, through simple prevention techniques such as hygiene training, fluoride therapy, tooth brushing and supplementary instruments, caries prevalence and periodontal diseases have been reduced significantly. As a result, the needs of treatments, that are mostly expensive and time consuming, have been decreased.3

The behavior of the people, in each society, is influenced by their knowledge and tendencies; on the other hand, the beliefs and tendencies of each society are also influenced by people’s behavior. Naturally, social and individual hygiene, depend on people’s knowledge. In order to promote useful hygienic habits among people and change their behavior, acomprehensive and accurate programme is necessary. Such an approach leads us to achieve in our cultural goals. One of the most effective factors, to reach these goals is to invest and pay special attention on oral hygiene training in schools to enhance students’ knowledge.4

Pupils' dental health attitudes could be explained by their present self-care practices in addition to the wish to adopt positive dental health behaviors in the future. Their ability to adopt these was further associated with their positive and negative perceptions of their own dental health. The close association between positive behaviors towards, and feelings of control over future dental health suggested that health attitudes could reflect feelings of empowerment and this was conductive to the adoption of self-care practices. Those pupils who felt empowered were more able to promote their own dental health by means of their positive self-care actions. On the other hands those groups of pupils which appeared less able to assimilate dental health information, which had less positive attitudes and were therefore unable to promote their own dental health through the adoption of self-care practices, could be identified.5

Materials and Methods:

The cross-sectional descriptive study was carried out in order to assess the attitude on oral hygiene among 1200 school children in selected schools of Dhaka city from December 2011 to March 2012. Students of class IV-IX (aged 10-15 years old) from one Non-Government and one government school of Dhaka were randomly selected and included in the study population.

Inclusion Criteria:

a) Only the student of class IV-IX (aged 10-15 years)were included as sample. b) Who are willing to give consent or participate to fill up the questioner. Exclusion Criteria: Students who refused to participate in the study.

Results:

A total number of 1200 respondents were participated through a structured checklist.

Table-1 showed that the mean age of the respondents was 12.5±0.5 (range 10-15) years. Among 1200 respondents, 50% of the respondents were studying in the government school and the rest (50%), in the private school. Seventy five percent (75%) were males and the rest (25%) were females. Of all, 85% was Muslims and the rest (18%) was Hindu.

Table-2 described the oral habit related variables of the respondents. Among the 1200 respondents, 69.2% brushed their teeth regularly and 30.8% did not. Among them, 69.2% brushed teeth once, 27.5% brushed twice and 3.3% brushed their teeth more than two times in a day. Ninety three percent (92.5%) used toothbrush, 5.8% finger and 1.7% used other materials for tooth brushing. Off all, 83.3% used tooth paste, 15.8%, tooth powder and 0.8% used other materials for brushed their tooth.

Discussion:

The variable “attitude” (“It is important to take care of my teeth”) was likewise included in our model. If the knowledge-attitude-practice relationship were a direct relation, introduction of the variable attitude would

Tlead to excellent fit, and the attitude and knowledge would be correlated. Attitude is only one factor determining behavior. Thus a subject with a highly positive attitude to tooth brushing, but with constraints that hinder daily brushing (for example, the child does not have a toothbrush, or no-one else in the family brushes their teeth), may not show straightforward translation of attitude to practice. As regards attitude to oral healthcare, 83% of subjects reported that it was very important to them to look after their teeth, and only 1.3% reported that looking after their teeth was unimportant.6

The present study showed that majority of respondents thought it was important to take care of oral cavity. Out of 1200 respondents, 92.5% reported it was important to take care of oral cavity, 6.7% thought that it was not important, while 0.8% did not know about it (Table-2).

A study in Jordan showed approximately 69% of the study sample brushed their teeth at least twice daily, while 17% reported irregular tooth brushing. Approximately 83% of the subjects reported using a toothbrush and toothpaste to clean their teeth. Two percent reported using dental floss, 6% reported using mouthwash, and 7% reported using tooth picks as extra aids for oral hygiene The study population did not brush their teeth at a similar time during the day. However, most subjects brushed their teeth before going to bed and/or in the morning. About 71% of the subjects took at least two minutes to brush while 15% took less than one minute. Most subjects showed awareness of the importance of tooth brushing for caries prevention (81%). Parents’ role in daily oral care was reported to be mainly related to giving advice on the importance of brushing (59%). Only 26% of the subjects reported being advised and watched by parents during brushing. Approximately 15% of the study sample reported that their parents never watched their brushing technique nor gave them advice onbrushing.7

The present study showed that 69.2% respondents regularly brushed their teeth while 30.8% were irregular in brushing. Again 69.2% respondents brushed their teeth at least once in a day, 27.5% brushed twice in a day while 3.3% brushed more than twice in a day. 92.5% respondents used toothbrush as brushing tools and 83.3% used tooth pest as dentifrices. 35%

responded report that they got information about oral care from parents as 65% did not. However 76.7% respondents think regular brushing prevents tooth decay while 20% did not think regular brushing prevents decay (Table-2). In a research, 300 high school students, at the age of (16 years ± 6 months) were investigated, Forty four percent of the students expressed lack of enough time as a reason for their irregular reference to dentist. Sixty two percent of the students brushed their teeth regularly and most of them (140 individuals) spent 2 to 5 minutes for brushing and just for 6.3% of them (19 individuals) tooth brushing took more than 5 minutes.8 Conclusions: The present study shows that an increase in knowledge about healthy habits will improve the oral health condition. As school going children’s are the future of a nations they should be targeted for developing those healthy habits and to improve the oral health.

References:

1. Department of Health. An oral health strategy for England, London: department of health, 1994.
2. La evidencia de la eficacia de la promoción de la salud. In “La evidencia de laeficacia de la promoción de la salud” edited and translated by the Spanish Ministerio de Sanidad y Consumo. RCOE 2002;7:537-45
3. Denielsen B, Manj F. Transition dynamics in experimental gingivitis in human. J Periodontol 1984,24:258-60.
4. Ullah MS, Aleksejunience J, Eriksen HM. Oral health of 12-year-old Bangladeshi children. Acta Odontol scand 2002;60(2):117-22.
5. Freeman R, Maizels J, Wylir M, et al. The relationship between health-related knowledge, attitude and dental health behavior in 14-16-year old adolescents. Com Dent Health 1993;10:397-404.
6. Smyth E, Caamaño F, Fernández-Riveiro P. Oral health knowledge, attitude and practice in 12-year-old schoolchildren. Med Oral Pathol Oral Cir Bucal 2007;12(8):E614-20.
7. Al-Omiri K, Al-Wahadni AM. Oral Health attitudes, knowledge and behavior among school children in North Jordan. J Dent Edu 2006:179.
8. Haghighati F, Mofidi F. An evaluation of high school female student’s knowledge and behavior regarding oral hygiene. Iranian J Publ Health 2006;35(1).

Introduction

Midline diastema is described as midline spacing greater than 0.5 mm between the proximal surfaces of adjacent teeth. Causes like ankylosed central incisor, flared or rotated central incisors , anodontia, macroglossia, dentoalveolar disproportion, localized spacing, closed bite, facial type, ethnic and familial characteristics, inter-premaxillary suture and midline pathology. Weber reported macrognathia, supernumerary teeth, peg laterals, missing lateral incisors, midline cysts and habits such as thumb sucking, mouth breathing and tongue thrusting1.

1. Dr. Mohammad Erfan Khondoker
   Lecturer, Dept of Periodontology & Oral Pathology Pioneer Dental College, Dhaka, Bangladesh.
2. Dr. Md. Arafat Kabir
   BDS, Ph.D, Post-Doc Associate Professor and Head, Department of Periodontology & Oral Pathology Pioneer Dental College, Dhaka, Bangladesh. Email: kabiranan@yahoo.com
3. Dr. Md. Farid Uddin
   Professor (CC), Head, Department of Conservative Dentistry & Endodontics Pioneer Dental College, Dhaka, Bangladesh.

• Address of Correspondence
• Dr. Md. Arafat Kabir
  BDS, Ph.D, Post-Doc Associate Professor and Head, Department of Periodontology & Oral Pathology Pioneer Dental College, Dhaka, Bangladesh. Email: kabiranan@yahoo.com

Angle concluded the presence of abnormal frenum as the cause for midline diastema2. Keene reported the incidences of maxillary and mandibular midline Diastema are 14.8% and 1.6% respectively3. During mixed dentition stage a transient midline diastema develops4.Treatment involves correct diagnosis and a early intervention relevant to its specific etiology. Different treatment modalities include orthodontic removable or simple fixed appliances, excision of the frenum, restoration techniques with direct composites, laminates, veneers, ceramic restorations, extraction of mesiodens, habit breaking appliances etc

CASEREPORT

A 19 year old female patient presented with a single diastema between maxillary central incisors (Fig 1a).The Diastema had been a aesthetic concern for an extended period of time. Medical and dental histories were completed and reviewed, care was taken to evaluate the complaint from the view point of the patient. Intraoral examination revealed presence of high frenum attachment and midline spacing between maxillary central incisors of 4mm. Tension test was done to confirm the attachment of the frenum to the marginal gingiva. Intraoral periapical radiograph was taken to rule out the presence of mesiodens. The attainment of a proportional aesthetic result required careful treatment planning and pretreatment identification of all potential treatment limitations. A Perio-Aesthetic-Restorative Multiphase Management was planned for the case and a informed consent was taken from the patient.

Perio – Aesthetic Management of Frenum

Mucogingival health is reflected in the periodontal aesthetic outcome and is also responsible for the restorative result. Here high frenum attachment was the major etiological factor causing midline spacing and precluded the maintenance of oral hygiene. Frenectomy was performed under local anesthesia. The frenum was engaged with a hemostat inserted to the depth of the vestibule. Incision was given with Bard Parker blade no.15 along the upper surface of the hemostat, extending beyond the tip. A similar incision was given along the undersurface of the hemostat. The triangular resected portion of the frenum was removed with the hemostat. This exposed the underlying brush like fibrous attachment to the bone (Fig 1c) A horizontal incision, separated the fibers. Sutures are given (Fig 1c).

Restorative Management of the Midline Diastema

Most of the Patient demand for aesthetic treatment with minimally invasive procedures. This has resulted in the extensive utilization of composite resin for the anterior teeth. The development of composite resins with natural fluorescence and polishability allows the clinician to mimic the natural dentition. Composite resin allows for conservative treatment and long lasting restorations. In order to achieve a natural appearing composite restoration, the clinician must have a knowledge of the properties of composites, and which materials to use in each clinical situation. There are a variety of materials to choose from including, microfills, hybrids, microhybrids, and the newer nanotechnology materials. Today's composite resins exhibit dramatically improved physical and optical properties, rendering them the ideal materials to facilitate restorations that are indistinguishable from the natural dentition. This case report demonstrates how current materials, techniques, and equipment can create subtle changes that will develop a new smile and meet a patient’s desired goals. Diastema closure required addition of composite to adjacent teeth. Gingival retraction was achieved by placing a plastic matrix subgingival while holding it against the lingual tooth surface. Diamond burs prepared tooth structure creating a rough surface for improved bond strength and to produce bevels that show through tooth color at restoration cavo surface areas. Cross section of enamel rods improves enamel bond strength. Depending on operator preference, either tooth could be restored first.

The most challenging part of this procedure is to get an excellent color match. Blending composite color to tooth color is achieved by proper composite selection, proper layering thickness and perfect placement. The left central incisor was acid etched for 20 seconds , rinsed and air dried. The enamel exhibited an excellent etch pattern. Bonding agent was applied and spread uniformly with air spray. No dentin was exposed; therefore only opacious Dentin and transparent Enamel resin was used. Material is usually placed incrementally and free hand sculpting for desired shape. The final restoration is cured for 40 secon

A layer of translucent composite is placed across the facial aspect, shaped with hand instruments and light cured. Final shaping and polishing is achieved with composite finishing burs. Mesial distal dimension is measured on the restored tooth and compared to the distal mesial dimension of the adjacent tooth and space. Adjustments are made to the restored tooth with burs or sandpaper disks. Restoration of the adjacent tooth is achieved using the same technique. Close approximation of composite to composite on the adjacent tooth is achieved by holding the matrix against the adjacent composite with an instrument and light curing (Fig 1e). Another problem with Diastema is that papilla is usually flat. This leads to the dual challenge creating a pointed papilla & completely closing the little black hole in the gingival embrasure. If the contact is extended gingivally & towards the lingual it can be used to create volume with the composite which will then push the papilla forward & incisally into the gingival embrasure on the facial of the contact. The back of the mouth is a dark area because it receives no light. Composite must block out darkness or a restoration appears dark. A opaque material placed on the lingual aspect so a natural looking restoration is achieved that is not influenced by this darkness. Restoring small Diastema or restoration of teeth that have a large buccal lingual dimension do not require placement of lingual opaque composite4. Composite resin is an ideal material when restoring diastema closures. It is highly polish able, long lasting, and can mimics natural tooth structure. It is a conservative alternative to an indirect restoration. Freehand bonding gives total control to the operator. Thus a favorable synergy between esthetics and function was achieved that would enhance the potential to have increased longevity in the life of the restorations5,6

1. Weber. Orthodontic principles & practice.GraberTM 3rd edi.WB Saunders Co:1972.
2. Angle EH. Treatment of malocclusion of the teeth.7th edi. SS white dental manufacturing Co.Philadelphia.1907:103-4.
3. Keene HJ. Distribution of diastemas in the dentition of man. Am J Phys Anthropol 1963;21: 437-41

1. Tait CH. The median frenum of the upper lip & it’s influence on the spacing of the upper central incisor teeth.Dental cosmos1934;76:991-2.
2. Carranzas Periodontolgy 9th edi.WB Saunders Co:2003.
3. Dietschi D. Free-hand composite resin restorations: A key to anterior aesthetics. Practical Periodontal Aesthetic Dentistry 1995;7(7):15-25..

Introduction

Pulpectomy is the preferred management modality for advanced carious progression and intraradicular infection -1. pulpectomy is a conservative treatment approach to prevent the premature loss of primary teeth can result in loss of arch length,- insufficient space for erupting permanent teeth,impaction of premolars and mesial tipping of molar teeth adjacent to the lost primary tooth.

1. Dr. Ashraful Alam Asif
   Lecturer, Depatment of paediatic dentistry, Pioneer Dental College & Hospital, Dhaka,Bangladesh
2. Dr. AtharAfif
   Intern Doctor, Pioneer Dental College & Hospital, Dhaka
3. Dr. Shams JerinSathi
   Intern Doctor, Pioneer Dental College & Hospital, Dhaka
4. Dr. Farzana Afreen Ria
   Intern Doctor, Pioneer Dental College & Hospital, Dhaka
5. Dr. Mahmudul Hassan Amin
   Intern Doctor, Pioneer Dental College & Hospital, Dhaka
6. Poffessor Dr. Rakiba Sultana
   Proffessor and head Depatment of Pediatric Dentistry, Pediatric Dentistry, Pioneer Dental College & Hospital, Dhaka

• Address of Correspondence
• Dr. Ashraful Alam Asif
  BDS, Lecturer, Dept. of Pediatric Dentistry, Pioneer Dental College & Hospital.
  email: asif.neel5528@gmail.com

History and clinical examination

A 6 years old boy reported to the department of pediatric dentistry of Pioneer dental college and hospital with complaints of pain on upper left posterior segment for 1 month and swelling for 3 days. On clinical examination patient had a gross caries on upper left second deciduous molar with extra oral swelling on left side.

Treatment plan and objectives

Patient history, clinical and radiographic examination revealed that is a case of chronic periapical abcess and treatment option was Pulpectomy of upper left second deciduous molar.

Treatment plan and progress

Removed all the remaining caries before removing the caries adjacent to the pulp. Roof of the pulp chamber was removed with high speed round with water coolant spray. After opening of pulp chamber no bleeding was noted from pulp chamber as well as canal. During locating canal with DG-16 there is slight indication of presence of pus with foul smell. So I decided to keep the pulp chamber open for 24 hours for the drainage of pus intra orally. The first visit of treatment was completed. Patient was advised with antibiotics and analgesic for pain and swelling. Patient was also advised to gurgle with warm saline water. On second visit the swelling was remarkably reduced as well as pain subsided. Coronal pulp was removed by sharp spoon excavator and radicular pulp was removed with barbed broach. Working length determination was done by radiographic method.

Working length was 13mm in mesiobuccal canal, 10 mm in distobuccal canal, 12 mm in palatal canal.Biomechanical preparation was done withk file upto 30 no. in palatal canal and 25 on both mesiobucal and distobuccal canal. Copious irrigation was done with normal saline. After full length preperationof canal calcium hydro oxide was given as intracanal medicament for 7days. After 7 days pain and swelling was subsided. After removal of

calcium hydroxide from canal irrigation was done with normal saline then canal was dried with paper point, Canal was sealed with zinc oxide eugenolsealer.

Results

After 7 days patient was recalled for follow up.Periapical radiograph was taken. Presence of swelling ,pusand other sign,symptoms was also subsided.Tooth was finally restored with glass ionomer cement..

Discussion

The basic idea of the treatment procedure was to preserve the deciduous tooth to mainytain its normal physiological function in the oral cavity and prevent malocclusion which may occur if the tooth was its normal shedding time. Weknow that premature loss of a primary tooth can result in loss of space for the permanent tooth and that leads to future problems during the eruption phase, so that’s why we want to maintain the tooth.

References

1. Swapnil H Mhatre.A single visit pulpectomy using Sxroytary pro taper file,World journal of dentistyoctober2012,10015-1192
2. Hany Mohamed Aly Ahmed .A review article on pulpectomy procedures in primary molar teeth ,European Journal of General Dentistry Vol -,January April 2014,1615