Author: Anisha Valli

Image Based Questions – Orthodontics – Part 2

Anisha ValliLeave a comment
  1. IDENTIFY THE SPACE MAINTAINER = BAND AND LOOP
  1. IDENTIFY THE APPLIANCE = DISTAL SHOE SPACE APPLIANCE
  2. IDENTIFY = ACTIVE TIE BACKS ***
  3. IDENTIFY = E- CHAIN
  4. IDENTIFY = GOLD CHAIN
  5. IDENTIFY = MONOCRYSTALLINE AND POLYCRYSTALLINE CERAMIC BRACKETS
  6. IDENTIFY THE TYPE OF ELASTICS = SETTLING ELASTIC
  7. IDENTIFY THE BRACKET = DAMON BRACKET
  8. IN WHICH SECTOR IS THIS CANINE IMPACTED = SECTOR 4
  9. IDENTIFY THE INSTRUMENT = SEPARATOR PLACING PLIER
  10. IDENTIFY = SPOT WELDER
  11. IDENTIFY = SAND BLASTER AND MICROETCHER
  12. IDENTIFY = WEINGART
  13. IDENTIFY = DELA ROSA

IDENTIFY = TWEED RIBBON ARCH PLIER**

Diagnosis Demystified – Case 2/255

Anisha ValliLeave a comment

A 63-year-old woman presented with exposed bone sequestrating from the mandibular alveolar ridge. Serum biochemistry showed that her alkaline phosphatase level was elevated 20-fold over the top of the normal range.

Alkaline phosphatase is a chemical that can be found in your body, and if it is found in high levels in the blood, it could be a sign of Paget’s disease of the bone. Paget’s disease is a condition where the bones in your body grow too much and become weak.

Also, if someone has a long-term bone infection in their jaws, this can cause a problem called bone sequestration. It means that a piece of dead bone gets separated from the healthy bone.

Paget’s disease is treated with a medication called bisphosphonates, which can help make the bones stronger. However, bisphosphonates have also been linked to a condition where the bone in the jaw can die, called osteonecrosis.

So, in summary, high levels of alkaline phosphatase can be a sign of Paget’s disease, and sometimes bone in the jaw can die from chronic osteomyelitis or treatment with bisphosphonates.

Image-based questions – Orthodontics – Part 1

Anisha ValliLeave a comment
  1. IDENTIFY THE APPLIANCE = K LOOP DISTALIZING APPLIANCE

  1. IDENTIFY THE APPLIANCE = MANDIBULAR ANTERIOR REPOSITIONING APPLIANCE

  2. IDENTIFY THE APPLIANCE = KLAPPER SUPER SPRING


  1. IDENTIFY THE APPLIANCE = RIBBON ARCH APPLIANCE


  2. IDENTIFY THE APPLIANCE = PIN AND TUBE APPLIANCE

    7: Orthodontic Appliances | Pocket Dentistry
  1. IDENTIFY THE FIGURE = NOLA DRY FIELD SYSTEM


  2. WHO GAVE THE FOLLOWING STAGES = MCNAMARA AND BACETI


  3. IDENTIFY THE BONE = TRAPEZIUM, TRAPEZOID, CAPITATE AND HAMATE


  4. IDENTIFY THE APPLIANCE = LINGUAL CLEAT
  5. IDENTIFY THE AUXILIARY = UPRIGHTING SPRING


  6. IDENTIFY = MECKEL’S CARTILAGE


  7. IDENTIFY THE STRESS LINE = RED, BLUE, ORANGE  AND PURPLE


  8. IDENTIFY THE FUNCTIONAL APPLIANCE = BIONATOR

  9. IDENTIFY THE FUNCTIONAL APPLIANCE = FUNCTIONAL REGULATOR


  10. IDENTIFY THE FUNCTIONAL APPLIANCE = TOOTH POSITIONER

Diagnosis Demystified – Case 1/255

Anisha ValliLeave a comment

A 28-year-old woman presented for a check-up. The dentist noticed that the occlusal plane was depressed on the left side. The molar teeth did not make contact with the maxillary teeth on that side, though wear facets were present.

ANSWER

So, your jaw is made up of two parts called the maxilla (which is the upper part) and the mandible (which is the lower part). The mandible has a part called the ascending ramus on each side, which is a bony projection that helps to support the jaw joint.

Sometimes, one side of the ascending ramus can grow more than the other side. This is called condylar hyperplasia. It can cause the jaw to become uneven, with one side being bigger than the other.

When this happens, the teeth on the bigger side can grow more than the teeth on the smaller side. This can cause the teeth on the bigger side to stick out more and make the bite uneven.

Does that make sense to you? Let me know if you have any more questions!

Drill Sergeant: Three Inspiring Dental Case reports of the week #1

Anisha ValliLeave a comment

1) Pouch and  tunnel technique in conjunction with connective tissue Graft -a paramount for treating gingival recession

Gingival recession can be a bothersome and unappealing issue for patients. Thankfully, there’s an esthetic correction option available that’s both minimally invasive and promotes fast healing: the Pouch and Tunnel technique with connective tissue grafting (CTG). This approach is an excellent alternative for patients seeking effective recession coverage, and it’s worth considering if they are looking for a solution that’s both friendly to gums and their wallet.

Link – https://doi.org/10.21276/10.21276/ujds.2021.7.1.17

2) The natural tooth pontic and instant idea to retain aesthetics

In cases where a patient experiences sudden tooth loss in the anterior region of their mouth, it can be distressing and affect their confidence. The good news is that there are a range of treatment options available, including removable, tooth-supported, and implant-supported prosthetics.

Regardless of the chosen treatment, it’s important to restore the patient’s smile as quickly as possible while also stabilizing their dental arch. One technique involves using the patient’s own natural tooth as a pontic, which provides an exact match in terms of size, shape, and color, while also preserving the original 3D position of the tooth.

Link : https://www.hindawi.com/journals/crid/2016/8502927/

3) Modified roll technique- handy technique to augment the periimplant soft tissue in aesthetic zone

In this randomized controlled trial, researchers are exploring the effectiveness of a modified roll flap (MRF) technique to enhance the appearance of single-tooth implants in the esthetic zone. The MRF is a pedicle flap that utilizes the gingival tissue overlying the covering screw to thicken the labial soft tissue, which can have a significant impact on the overall esthetic outcome.

The study aims to measure the thickness of the labial soft tissue and the implant esthetic score system (IES) to evaluate the success of the MRF technique during stage-two implant surgery. By preserving and utilizing the existing tissue instead of discarding it, the MRF technique could potentially enhance the appearance of the implant site and improve patient satisfaction with the results.

Link: https://www.sciencedirect.com/science/article/pii/S1687857413000231

STAGES OF GINGIVITIS #NEETMDS #Pearls

Anisha ValliLeave a comment
  1. Stage 1 – Initial stage
    1. Starts at 2 – 4 days after beginning of plaque accumulation 
    2. Increase vascularity 
    3. Increase GCF flow 
    4. Stage of subclinical gingivitis = no clinical changes
    5. Immune cells = PMNs are main line of defense
    6. Important feature = increase in GCF flow 
  2. Stage 2 – Early stage
    1. Early lesion evolves from initial lesion 4 – 7 days after the beginning of plaque accumulation 
    2. Clinical signs appear in this stage
      1. BOP 
      2. Erythema 
    3. Important feature = clinical signs appear 
    4. Immune cells = lymphocytes 
    5. Collagen destruction increases
      1. 70% of collagen fibers are affected
      2. Main fiber groups involved
        1. Circular 
        2. Dentogingival
  3. Stage 3 – Established lesion
    1. Severely inflamed gingiva/chronic gingivitis 
    2. It occurs for 14 – 21 days after the beginning of plaque accumulation 
    3. Immune cells = Plasma cells 
    4. Important feature = change in color, size, texture 
    5. Bluish hue on the reddened gingiva
      1. Blood flow sluggish 
      2. Impaired venous return 
  4. Stage 4 – Advanced lesion
    1. Gingivitis progresses to periodontitis 
    2. CT loss 
  • Gingivitis is T-cell lesion 
  • Periodontitis is B cell lesion 
  • When gingivitis is dominated by T cells = Contained gingivitis 
  • Term subclinical gingivitis was coined by LINDHE, synonym of stage 1 
  • Number of transmigrating leukocytes and amount of GCF = between 6 to 12 days of gingivitis = these values become maximum 

Age Changes in the Periodontium #NEETMDS #Pearls

Anisha ValliLeave a comment

GINGIVAL EPITHELIUM 

  1. Keratinization = decreases 
  2. Epithelium = thinner 
  3. JE migrates apically 
  4. Width of attached gingiva – decreases 

GINGIVAL CONNECTIVE TISSUE 

  1. Collagen
    1. Soluble to insoluble 
    2. Denser and coarser
    3. Mechanical strength of collagen decreases
    4. Number of
      1. Collagen fibers decrease 
      2. Elastic fibers increase
  2. Periodontal Ligament
    1. Collagen decrease 
    2. Number of cells increase 
    3. Tensile strength decrease
  3. Cementum
    1. Width increases 
  4. Alveolar bone
    1.  Weaker 
    2. Amount of cortical and compact bone decreases 

Anatomy of the Periodontium #NEETMDS #Pearls 

Anisha Valli1 Comment

Gingiva divided into

  1. Marginal 
  2. Attached
  3. Interdental papilla

Marginal gingiva 

  1. Demarcated from attached gingiva by free gingival groove – this is also called marginal groove 
  2. Width = 1 mm 
  3. Gingival Zenith = most apical point on the marginal gingival scallop 
  4. It’s dimensions vary between 0.06 to 0.96 mm

GINGIVAL SULCUS 

  1. V shaped space/ Crevice 
  2. On one side – there is tooth tooth, on other side – gingival epithelium 
  3. Depth
    1. Ideal = 0 mm – germ free individuals and controlled environment 
    2. Histological sections = 1.8mm [ 0-6mm]
    3. Probing depth at apical termination of probe = 2-3mm 

ATTACHED GINGIVA 

  1. Firm and resilient 
  2. Demarcated from alveolar mucosa by – mucogingival junction
  3. Width of attached gingiva
    1. Greatest in maxillary incisors 3.5 -4.5 mm and mandibular incisors 3.3 – 3.9 mm 
    2.  Least in maxillary premolars 1.9 mm and mandibular premolars 1.8mm
    3. Width of attached gingiva increases with age in supraerupted teeth 

INTERDENTAL GINGIVA / PAPILLA

  1. Occupies gingival embrasure 
  2. Shape can be pyramidal/col 
  3. Col covered by non keratinized epithelium 

MICROSCOPIC FEATURES OF GINGIVA 

Composed of epithelium and connective tissue 

Gingival epithelium 

  1. Type = stratified squamous epithelium 
  2. Cells
    1. Principal cells = Keratinocytes = bulk 
    2. Melanocytes 
    3. Langerhans cells 
    4. Merkel cells 
    5. B,c,d = non keratinocytes 
  3. Four layers 
    1. Stratum corneum 
    2. Stratum granulosum 
    3. Stratum spinosum 
    4. Stratum basale 
  4. Three types of epithelium on basis of differentiation
    1. ORTHOKERATINIZED
      1. Stratum corneum = NO Nucleus 
      2. Keratin hyaline granules are evenly dispersed in Stratum granulosum
    2. PARAKERATINIZED
      1. No Stratum granulosum 
      2. Stratum corneum = retains PYKNOTIC nuclei 
    3. NON-KERATINIZED
      1. 2 layers are present = basale and spinosum 
      2. Upper most cells = retain VIABLE nucleus 

KERATINOSOMES OR ODLAND BODIES

  1. Modified lysosomes 
  2. Found in Stratum spinosum 

MELANOCYTES 

  1. Found in basal layer and spinosum layer
  2. Function = production of melanin 

LANGERHANS CELLS 

  1. Seen in suprabasal level
  2. Antigen presenting cells 
  3. Part of reticuloendothelial system 
  4. Contain birbeck granules 

MERKEL CELLS 

  1. Basal and Spinosum = deep layers
  2. Act as tactile receptors 

BASAL LAMINA

  1. Connecting link between epithelium and connective tissue 
  2. Thickness – 300 to 400 A and lies 400 A beneath the epithelial basal layer 
  3. Consists of two layers
    1. Lamina lucida
      1. Rich in laminin protein
    2. Lamina densa
      1. Rich in collagen type 4
  4. Basal lamina is connected to connective tissue by Hemidesmosomes ** and Anchoring Fibrils (750 nm)

KERATINIZATION OF ORAL MUCOSA IN DECREASING ORDER 

  1. HARD PALATE = most keratinized 
  2. Buccal mucosa = least keratinized 

OUTER EPITHELIUM 

  1. Covers the crest or outer surface of marginal gingiva and attached gingiva 
  2. 0.2-0.3 um

SULCULAR EPITHELIUM 

  1. Lines gingival sulcus 
  2. Non keratinized**
  3. Semi permeable 

KERATINS

  1. K1, k2, k10-k12 = epidermal type differentiation 
  2. K6 and k16 = proliferation specific 
  3. K5 and k14 = Stratification specific 
  4. K19 = present in parakeratinized epithelium and absent in orthokeratinized epithelium 

JUNCTIONAL EPITHELIUM 

  1. Non keratinized 
  2. Langherhans cells are absent 
  3. Thickness
    1. Early – 3-4 cells 
    2. Later – 10 – 20 cells 
  4. Length = 0.25 – 1.35 um 
  5. Formed by REE + OE
  6. Attachments
    1. Attached to tooth by internal basal lamina 
    2. Attached to CT by external basal lamina 
  7. Produces = Laminin from lamina lucida of basement membrane 
  8. Dentogingival unit
    1. Junctional Epithelium + Gingival fibers 
    2. Function = brace gingiva against tooth 

BLOOD SUPPLY TO THE GINGIVA 

  1. Supraperiosteal arterioles 
  2. Arterioles emerging from interdental septa 
  3. Vessels of periodontal ligament 

GINGIVAL FIBERS 

  1. Dentogingival group
    1. Found in maximum number 
  2. Alveologingival group 
  3. Circular group 
  4. Dentoperiosteal 
  5. Transeptal fiber group 

SUPRACRESTAL FIBERS 

  1. Type of transseptal fibers
  2. Important fibers during relapse of orthodontic treatment 

PERIODONTAL LIGAMENT

PERIODONTAL FIBERS

  1. Principal fibers
    1. made up of collagen type 1 
    2. Produced by fibroblasts 
  2. Transseptal fibers
    1. Gingival + periodontal 
    2. Reconstructed even after bone loss**
  3. Alveolar crest fibers
    1. Prevent extrusion 
    2. Resist lateral forces 
  4. Horizontal fibers
  5. Oblique fibers
    1. Largest group of fibers 
    2. Resist vertical forces
  6. Apical fibers = absent in incomplete roots 
  7. Interradicular fibers 

RESISTANCE TO IMPACT OF OCCLUSAL FORCES (SHOCK ABSORPTION)

  1. TENSIONAL THEORY 
    1. Major importance to PDL
    2. Best forces = longitudinal forces 
    3. Worst forces = torsional forces 
  2. VISCOELASTIC THEORY 
    1. Dental fluids helps in transfer of forces 

CEMENTUM 

  1. Avascular tissue
  2.  Forms the outer covering of anatomical root 
  3. Two types
    1. Primary cementum
      1. Acellular cementum
      2. Forms before eruption
      3. Covers 1/3rd of root 
    2. Secondary cementum
      1. Cellular cementum
      2. Formed after eruption 
      3. Covers apical third of root 
  4. Main sources of collagen fibers in cementum
    1. Extrinsic fibers
      1. Produced by fibroblasts – called as Sharpey’s fibers**
    2. Intrinsic fibers
      1. Produced by cementoblasts
  5. Cementum classification by schroeder**
    1. Acellular afibrillar cementum
      1. No cells/fibers
      2. Formed by cementoblasts 
      3. Found as coronal cementum 
      4. Thickness – 1 to 15um 
    2. Acellular extrinsic fiber cementum
      1. Contain only sharpey fibers and lack cells 
      2. Formed by both fibroblasts and cementoblasts 
      3. Found in cervical third of roots 
      4. Thickness = 30 to 230 um 
    3. Cellular mixed stratified cementum
      1. Both intrinsic and extrinsic fibers + cells 
      2. Formed by both fibroblasts and cementoblasts 
      3. Present in apical third of roots and furcation
      4. Thickness = 100 to 100um
    4. Cellular intrinsic fiber cementum
      1. Cells 
      2. Formed by cementoblasts 
      3. Fills resorption lacunae

1, 4 = produced by cementoblasts only 

2 and 4 = cementoblasts + fibroblasts 

INTERMEDIATE CEMENTUM 

  1. Poorly defined zone near Cementodentinal junction
  2. Contains remnants of HERS embedded in calcified ground substance 

INORGANIC CONTENT OF CEMENTUM (45-50%)

  1. Bone = 65 – 70%
  2. Enamel = max content = 92- 96%
  3. Dentin = 50 – 60%

CEMENTOENAMEL JUNCTION 

  1. 60 – 65% = C overlaps E
  2. 30% = butt joint = C and E just meet 
  3. 5 – 10% = C and E does not meet

CEMENTODENTINAL JUNCTION 

  1. When RCT is performed, the obturating material should be at the CDJ 
  2. CDJ is 2 – 3 um wide 

ANKYLOSIS 

  1. Resorption of PDL
  2. Direct connection between tooth and bone 
  3. Cementum resorption is present 

ALVEOLAR PROCESS 

  1. External plate of thick cortical bone 
  2. Inner socket wall of compact bone = also called alveolar bone proper 
  3. Seen as Lamina dura in radiographs 
  4. Histologically
    1. Series of openings = cribriform plates
    2. Through which neurovascular bundles pass 
  5. Supporting alveolar bone = made up of cancellous bone
  6. Basal Bone = unrelated to teeth but it is the most apical part of alveolar bone/jaw 
  7. Interdental septum consists of cancellous supporting bone which is enclosed within a compact border

Salivary Gland Disorders #NEETMDS #Pearls

Anisha ValliLeave a comment

MUCOCELE

  1. Mucin filled cavity
    1. Mucous extravasation phenomenon = PSEUDOCYST
    2. Mucous retention cyst = TRUE CYST
  2. Dome shaped swelling 
  3. MC site = lower lip 
  4. Superficial lesion = bluish, translucent 
  5. Deeper = color and surface is normal 
  6. Pseudocyst = Lined by compressed connective tissue
  7. True cyst = cystic cavity is lined by ductal epithelium
  8. MEP is more common than MRC

RANULA 

  1. Form of mucocele 
  2. Present in floor of mouth 
  3. Lateral to midline 

PLUNGING RANULA 

  1. Mucocele dissects through mylohyoid muscle 
  2. Swelling in the neck 
  3. Cervical Ranula

SIALOLITHIASIS 

  1. Stone present in gland or duct 
  2. Associated with submandibular gland
    1. Saliva production = high in mucin and binds to foreign particles 
    2. Duct is long and tortious 
    3. Antigravity direction 
  3. Bimanual Palpation 
  4. Occlusal radiograph to diagnose

SIALADENITIS 

  1. Itis means inflammation 
  2. Inflammation of salivary glands due to
    1. Infection = mc viral infection of parotid gland = mumps 
    2. Non infectious 

SJOGREN SYNDROME 

  1. MC autoimmune disease of salivary glands
  2. Primary = dry eyes + dry mouth = sicca syndrome 
  3. Secondary = Primary + Rh arthritis or SLE or Scleroderma
  5. H/p = Infiltration of lymphocytes = Destroy the normal architecture of gland 
  6. Few remnants of gland is left behind = Epimyoepithelial islands
  7. Diagnostic criteria
    1. Ocular symptoms >3 months
    2. Oral symptoms >3 months
  8. Tests for Ocular symptoms
    1. Schirmer’s test = less than 5 mm in 5 mins 
    2. Rose bengal test = less than 4 = positive 
  9. Tests for Oral symptoms
    1. Unstimulated salivary flow = less than 1.5 ml in 15 mins 
    2. Sialography = cherry blossom pattern or branchless fruit laden tree pattern or apple tree pattern
    3. Radioactives dyes = Scintigraphy 
  10. Histopathology
    1. Site of biopsy = lower lip or labial mucosa which is clinically normal 
    2. 4mm2 = more than 50 lymphocytes 
    3. 4mm2 = more than or equal to 1 focus score
  11. Serological tests = Antinuclear antibodies
    1. Anti Ro ( Anti SS- A)
    2. Anti La (Anti SS – B)
  12. Exclusion Criteria
    1. Past head and neck radiation – xerostomia 
    2. Hepatitis C infection 
    3. AIDS
    4. Preexisting lymphoma 
    5. Sarcoidosis 
    6. Graft vs Host disease
    7. Use of anticholinergic drugs – dry mouth 

MIKULICZ DISEASE 

  1. MILDER FORM of sjogren syndrome 
  2. Improvements with steroids – not seen in SS
  3. No cherry blossom pattern is seen 
  4. Also called benign lymphoepithelial lesion of SG 
  5. Presence of epimyoepithelial islands 

SIALADENOSIS 

  1. Non inflammatory salivary gland enlargement 
  2. Sialography – leafless tree pattern 

NECROTIZING SIALOMETAPLASIA

  1. Locally destructive inflammatory condition
  2. Cause – ischemia leading to tissue infarction 
  3. Crateriform ulcer = mimic SCC clinically and histologically
  4. Resolve spontaneously 
  5. Average healing time is approx = 5 weeks  
  6. Epithelial islands in connective tissue
    1. In SCC = cells are dysplastic 
    2. In NSM = cells are not dysplastic 
  7. Also called Pseudocarcinomatous hyperplastic 
  8. Also called Epitheliomatous 


SALIVARY TUMORS

  1. MC salivary gland neoplasm 
  2. Its benign SG neoplasm 
  3. MC site = parotid and palate
  4. Slow growing 
  5. Facial Paralysis = rare 
  6. Epithelial component = Islands or ducts 
  7. CT components
    1. Myxomatous areas 
    2. Chondroid
    3. Osseous 
    4. Hyalinized 
  8. All these components are derived from Ductal reserve or Myoepithelial cells 
  9. Hence, its pseudo mixed tumor H/P
  10. Eosinophilic coagulum is surrounded by hyaline areas
  11. Plasmacytoid cells = look like plasma cells – eccentric nucleus
  12. Myxomatous = Increase in mucoid material 
  13. Vacuolar degeneration of cells = Chrondroid area
  14. All these components are seen in Pleomorphic Adenoma

WARTHIN’S TUMOR 

  1. Also called adenolymphoma 
  2. Almost exclusively seen in parotid gland 
  3. Pathogenesis = Heterotopic salivary gland tissue in para-parotid lymph nodes 
  4. Smokers have 8 fold higher risk 

PAPILLARY CYSTADENOMA LYMPHOMATOSUM 

  1. Papillary projections into lumen 
  2. Core is made of lymphocytes
  3. Aspirate = chocolate brown coloured 
  4. Prone to develop lymphoma 

MUCOEPIDERMOID CARCINOMA 

  1. MC malignant SG neoplasm 
  2. MC in parotid and palate
  3. Facial Paralysis is seen 
  4. H/p 
Low grade Good Prognosis 
Intermediate grade
High GradeWorst Prognosis 
Cystic/ SolidCellular atypiaMucous cells/ Epidermoid cells/intermediate
Low grade morelessmore
Intermediate 
High Grademoremoremore
  1. Low grade
  2. High Grade 

ADENOID CYSTIC CARCINOMA 

  1. Old term = cylindroma = now rejected 
  2. Palate = 50% cases
  3. Parotid – Facial paralysis is seen 
  4. Invades and splits nerves = Perineural invasion and spread = This is also seen in Polymorphous low grade adenocarcinoma
  5. Cribriform Pattern
    1. lots of cystic spaces
    2. Swiss cheese pattern 
  6. Tubular pattern = Tumor cells are arranged in form of tubules 
  7. Solid pattern
    1. Very rare 
    2. Arranged in islands 
    3. Highly aggressive 
    4. Worst prognosis 

TAURODONTISM #NEETMDS

Anisha Valli1 Comment

  1. Also called as Bull’s teeth
  2. Increase in size of crown 
  3. Decrease in size of root 
  4. Abnormally large sized pulp chambers 
  6. CLASSIFICATION = Ratio of crown body/ root 
  8. Syndromes associated with 
    1. Klinefelter syndrome 
    2. Type 5 AI 
    3. Down syndrome 
    4. Ectodermal dysplasia
    5. Tricho Dento Osseous syndrome
      2. Tricho = Kinky coiled 
      3. Dento = Enamel hypoplasia and Taurodontism 
      4. Osseous = Sclerotic bone