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                                                         Volume 1                                   Issue No 1                                March - April 2010




                                                                    A PERSONAL ORTHODONTIC
                         ro                                              PERSPECTIVE AND
                                                                     HISTORICAL COMMENTARY
                                                                    AFTER THE FIRST 100 YEARS.
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                                                                            Editor in chief
                                                                             Dr Viren K Puri
                                                                                                                                                                              A PERSONAL ORTHODONTIC PERSPECTIVE
                                                                                 Editors                                                                                      AND HISTORICAL COMMENTARY AFTER
                                                              Dr PS Viswapurna & Dr Ashutosh Shetty
                                                                                                                                                                              THE FIRST 100 YEARS.




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                                                                            Editoral board                                                                                                                                                                                                             T.M. Graber
                                                                                                                                                                                                                                                                 DMD, MSD, PHD, Odont.Dr. DSc, ScD, MD, FRCS
                      Dr Rafi Romano (Isreral)                                                            Dr George Risse, (Germany)
                                                                                                                                                                                                                                                                   Professor, University of Illinois, Chicago, USA
                       Dr Kannan Balaraman                                                                     Dr Sanjay Pasupathy
                         Dr Sathesh Kumar                                                                        Dr Gowri Shankar
                    Dr Sabarinathan (Malaysia)                                                           Dr Karthikeyan Sundram (UK)




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                                                                                                                                                                         On the cornerstone of the Bureau of                                             Over a century has past since orthodontics, FKO, dentofacial orthopedics
                            Dr Badari (UK)                                                                        Dr Andre K (UK)                                        Documents of the United States                                                  were recognized as a specialty, the first officially recognized dental
                                                                                                                                                                         Government in Washington D.C., not far                                          specialty! We are truly one world of orthodontics, and pioneers from many
                     Dr Ragunathan Hari (UK)                                                                     Dr B S Saravanan                                        from the impact of that plane on that                                           countries, as well as training in these countries, have brought us to the
                                                                                                                                                                         fateful 9/11 day in 2001, is engraved                                           present high level of achievement of patient care. This beautiful mosaic of
                   Dr Badar Monir Zaki (Oman)                                                              Dr Hussain Allawat(Oman)                                      the following: The heritages of the past                                        art, science, physiology, growth guidance and biomechanics is the
                    Dr Zaher Al-Riyami (Oman)                                                                 Dr Manjunath (Oman)                                        are the seeds that bring forth the                                              culmination of the contributions of the efforts of farsighted, dedicated
                                                                                                                                                                         harvest of the future. No statement                                             cranio-facial biologists and clinicians from around the world. Truly team
                   Dr Prabu Duraiswamy (Libya)                                                                    Dr Vigneswaran                                         could be more appropriate, yet we tend                                          effort! My objective for this article to our colleagues and friends in India is
                                                                                                                                                                         to forget the past and repeat the same
                Dr Alagesan Chinnaswamy (Libya)                                                                     Dr Guru E N                                                                                                                          to outline the contributions to our orthodontic compendium of knowledge
                                                                                                                                                                         mistakes over and over again.
                                                                                                                                                                                                                                                         from the United States and Canada, admittedly strongly dependent on
                           Dr Dhiraj Shetty                                                                      Dr M N Kuttappa                                         Over a century has past since                                                   contributions from our European, Arab and Asian colleagues. After a brief
                                                                                                                                                                         orthodontics, FKO, dentofacial                                                  outline of non-American literature on orthodontics which formed the basis
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                                                                                                                                                                         orthopedics were recognized as a




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                           Dr A T Prakash                                                                        Dr Akshay Shetty                                                                                         Edmund Wuerpel, Artist         for American clinical and research efforts the past 100 years (I have many of
                                                                                                                                                                         specialty, the first officially recognized
                         Dr Mitha M Shetty                                                                       Dr Ashish Shetty                                                                                                                        these original volumes in my personal library and our departmental library at
                                                                                                                                                                         dental specialty! We are truly one world of orthodontics, and pioneers from
                                                                                                                                                                                                                                                         the University of Illinois), I will concentrate on early American dentists who
                                                                                                                                                                         many countries, as well as training in these countries, have brought us to
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                       Dr Yadav Chakravathy                                                                        Dr Ramkumar                                                                                                                           helped make our specialty what it is today.




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                                                                                                                                                                         the present high level of achievement of patient care. This beautiful mosaic
                           Dr Rajesh Reddy                                                                       Dr Prashanth G S                                        of art, science, physiology, growth guidance and biomechanics is the             Much of my stimulus has been from having been fortunate enough to have
                                                                                                                                                                         culmination of the contributions of the efforts of farsighted, dedicated        met, associated with in actual practice and learned from so many of these
                          Dr Prashanth C S                                                          Dr Karthigeyan Loganathan (Malaysia)                                 cranio-facial biologists and clinicians from around the world. Truly team       orthodontic pioneers. Through them, their recounting of their own
                                                                                                                                                                         effort! My objective for this article to our colleagues and friends in India is experiences has provided a remarkable record of those early, formative
                                                                                                                                                                         to outline the contributions to our orthodontic compendium of knowledge         years. I use these personal connections and recollections as a basis for my
                                                                                                                                                                         from the United States and Canada, admittedly strongly dependent on             overview.
Photocopying
                                                                                                                                                                         contributions from our European, Arab and Asian colleagues. After a brief
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                                                                                                                                                                         outline of non-American literature on orthodontics which formed the basis        I entered Washington University in St. Louis in January, 1935. In my pre-
Single photocopies of single articles may be made for personal use. Permission of the Publisher is required for all other photocopying, including multiple or
                                                                                                                                                                         for American clinical and research efforts the past 100 years (I have many of   dental college program, I took a course on art appreciation from Edmund
systematic copying, copying for advertising or promotional purposes, resale, and all forms of document delivery.
                                                                                                                                                                         these original volumes in my personal library and our departmental library at   Wuerpel, Dean of the School of Fine Arts at Washington University Little did I
Derivative Works                                                                                                                                                         the University of Illinois), I will concentrate on early American dentists who  know that he had played such a prominent role in orthodontics in general and
                                                                                                                                                                         helped make our specialty what it is today.                                     the life of Edward H. Angle and his students particularly.
Subscribers may reproduce tables of contents or prepare lists of articles including abstracts for internal circulation within their institutions. Permission of the
Publisher is required for resale or distribution outside the institution.                                                                                                 Much of my stimulus has been from having been fortunate enough to have         Entering the dental school in the fall of 1936, my dean (and orthodontic
                                                                                                                                                                         met, associated with in actual practice and learned from so many of these       department head) was Benno E. Lischer, who had written one of the first
Electronic Storage or Usage                                                                                                                                              orthodontic pioneers. Through them, their recounting of their own               biologically and physiologically oriented orthodontic textbooks in 1912.
Permission of the Publisher is required to store or use electronically any material contained in this journal, including any article or part of an article               experiences has provided a remarkable record of those early, formative          Between Wuerpel and Lischer, with their fascinating lectures, I was oriented
                                                                                                                                                                         years. I use these personal connections and recollections as a basis for my     toward orthodontics early on! The first page of his orthodontic textbook
Except as outlined above, no part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic,            overview.                                                                       quoted Dr. Frederick B. Noyes' definition of “orthodontia” as , “the Study of
mechanical, photocopying recording or otherwise, without prior written permission of the Publisher.                                                                       I entered Washington University in St. Louis in January, 1935. In my pre-      the relation of the teeth to the development of the face and the correction of
Notice                                                                                                                                                                   dental college program, I took a course on art appreciation from Edmund         arrested and perverted development.” Little did I know that I would also have
                                                                                                                                                                         Wuerpel, Dean of the School of Fine Arts at Washington University On the        the opportunity to associate with the venerable “Dr. Fred” and his son, Harold
No responsibility is assumed by the Publisher for any injury and/ or damage to persons or property as matter of products liability, negligence or otherwise, or from     cornerstone of the Bureau of Documents of the United States Government in       Judd Noyes for five years later on in my own early orthodontic career!
any use or operation of any methods, products, instructions or ideas contained in the material herein. Because of rapid advances in the medical sciences, in             Washington D.C., not far from the impact of that plane on that fateful 9/11
particular, independent verification of diagnoses and drug dosages should be made.                                                                                       day in 2001, is engraved the following: The heritages of the past are the
                                                                                                                                                                         seeds that bring forth the harvest of the future. No statement could be more                        “We can not do great things. We can only
                                                                                                                                                                         appropriate, yet we tend to forget the past and repeat the same mistakes                                  do little things with great love”.
                                                                                                                                                                         over and over again.
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                                                                      March - May                   1                                                                                                                                    March - May                2
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                                                                                  Edward H. Angle later referred to Kingsley as “Orthodontia's greatest                                                                                               I present this brief outline of the early international contributions to show that
                                                                                  genius”.                                                                                                                                                            our beloved specialty is the result of efforts of an international team, each
                                                                                  John Nutting Farrar's text appeared in 1888, entitled “Irregularities of the                                                                                        one learning from the others, but not always giving credit.
                                                                                  Teeth”.                                                                                                                                                             I return to my own experiences with many of the early orthodontic leaders.
                                                                                  It was truly a veritable gold mine and was referred to as “epoch-making” by                                                                                         Tragically, Lischer and Angle were lifetime enemies, after Angle turned him
                                                                                                                                                                                                                                                      down for entrance to his private Angle school, when he learned that Lischer
                                                                                  Dr. Lischer in his lectures. Farrar was considered as the founder, not only of
                                                                                                                                                                                                                                                      wanted to practice in the same citySt.
                                                                                  “systems”, but of present day appliances and methodology. Tragically,




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               Kingsley headcap (extraoral force)                                                                                                                                                                                                     Louis. (Angle's comment was, “You
                                                                                  because of personal antagonisms, his work was largely ignored by many                                                                                               know, Lischer, I can pick the flowers in
               Kingsley skeleton skull cap, as he called it.                      contemporaries and did not receive the recognition it deserves from                                                                                                 my own garden myself!”) This personal
                                                                                  historians. Lischer felt that much of the scientific background of                             Calvin Case                       Edward. H. Angle                   animus does not detract from the
                                                                                  orthodontics was presented for the first time in textbook form by Farrar. Later                                                                                     contributions of both men. Angle
But the die was cast after exposure to the dynamic, biologically oriented         textbook efforts by others quoted liberally from his book, without giving         An early supporter of Angle, Calvin Case later became concerned with the          taught at Minnesota, Northwestern
lectures by Dr. Lischer, who was of a prolific reader of distinguished German                                                                                       total rejection of “extraction of teeth at any cost” and the commercialism by     and St. Louis University before finding
                                                                                  credit, often taking credit for themselves.
heritage and fluent in both German and French. He quoted the work of F.C.                                                                                           the Angle system proponents, thereby incurring the wrath of Angle, and his        the academic environment
Kneisel, entitled Der Schiefstand der Zähne in both German and French             An American icon of the early years was Calvin Case, one of the first             disciples. The celebrated Case/Dewey debate in 1911 settled no issues, but        incompatible with his goals. A fine text




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languages, published in 1836, Bunon (1742), Bordelette (1757), Berdmore           orthodontic specialists in Chicago (1891). He is perhaps remembered most          further divided the Angle group from the rest of the American orthodontists.      by Wilbur Shankland on the history of
(1770), Fox (1803), Delabarre (1803), and Catalan (1808). The orthodontic         around the world for his work with cleft lip and palate children. Modern          Anna Hopkins, long time secretary from the early 1890s, later his wife after      the American Association of
subject was, of course, covered in other textbooks along with other phases        obturators differ little in design from his original versions. By fortunate       their marriage in 1908, wrote most of the Angle correspondence for him,           Orthodontists and the lives of many
of dentistry, books by Linderer (1842), Carabelli (1844) and a series of books    circumstances, I opened my private practice of orthodontics in Kenilworth,        actually graduating from the University of Iowa in 1904 as a dentist.             leaders is a “must” reading assignment
in the English language . Clearly, these served as a basis for later American     Illinois, a northern suburb of Chicago, one block from where Calvin Case had                                                                                        to understand the ebb and flow of
                                                                                                                                                                    Martin Dewey was a student of Angle, but like so many of these early                                                             Anna Hopkins Angle
texts. In 1880, Norman Kingsley published the first American text in                                                                                                                                                                                  information, as well as invective, in
                                                                                  lived . It was a mecca for me with historical guidance from Charles Reeder        followers, he deviated from the Angle dictum, formed his own Dewey School
orthodontics, entitled “Oral Deformities.”                                                                                                                                                                                                            those formative years. Benno Lischer turned early to the sciences of
                                                                                  Baker, first head of orthodontics at Northwestern University and a former         of Orthodontia and wrote a very good orthodontic textbook. But the bitter
An outstanding teacher, artist and the first dean of New York College of          president of the American Association of Orthodontists. I did my Ph.D.            rivalry and personal attacks lasted a lifetime.                                   anthropology and anthropometry and the role of the neuromusculature in
Dentistry, he refused to be drawn into the individual rivalries and                                                                                                                                                                                   craniofacial morphology, rather than concentrating on teeth alone and
                                                                                  Dissertation on Cleft Lip and Palate treatment and growth and                     It certainly is true that the early orthodontic pioneers in America indulged in
antagonisms among the early orthodontic pioneers. Several chapters on                                                                                                                                                                                 mechanical contrivances. It was through his teachings that I, as his student,
                                                                                  developmental implications, at Northwestern University Medical School in          considerable personal invective, as they sought to establish their own pre-       saw the role of orthodontists as applied biologists, not just “tooth
malocclusion of teeth, etiology of malocclusion, diagnosis and treatment,         1950, largely because of Calvin Case. I had the eminent Leslie Arey and Harry     eminence and priority of claims for specific “treatment rationale and             straighteners”, the prevailing concept of orthodontic orthodoxy in North
plus a discussion of cleft lip and palate and fractures of the jaws made this a   Sicher, world class scientists, as my directors!                                  systems.” Orthodontics was a dogma, a religion. Ray Begg of Australia, a          America in those early years! Lischer's book, “Time to Tell”, published at the
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landmark volume. His early extraoral orthopedic appliances look amazingly                                                                                           student of Angle early on, told an American orthodontic meeting in
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                                                                                                                                                                                                               or
                                                                                                                                                                                                                                                      end of his life in 1957, is a fascinating recounting of those formative years
contemporary.                                                                                                                                                       Washington D.C in 1954, “This is the way to do it! If you vary it one iota from   and the sacrifice of facts and reputations due to personal antipathies. It was
                                                                                                                                                                    my technique, I've tried it already and it failed!”                               a rare and wonderful experience for me to be a student of Benno Lischer and
                                                                                                                                                                    Those historical orthodontic building blocks at the turn of century include the   to listen to him talk about music, art, literature and dentistry. He was not
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                                                                                                                                                                    work of Walkoff, Die Unregelungen mässigkeiten in den Zahnstellungen und          exactly the mechanical prototype of most dentists.
                                                                                                                                                                    Ihre Behandlung which was published in 1891; a pretentious volume by              The influence of European colleagues is obvious, though too many early
                                                                                                                                                                    Colyer (1900), Irregularities of theTeeth (England) ; an excellent text by
                                                                                                                                                                                                                                                      American orthodontists were essentially appliance-oriented. But Albin
                                                                                                                                                                    MacDowell, of Northwestern University in Chicago, in 1901, the works of




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                                                                                                                                                                    Knapp and of Jackson, Orthodontia and Orthopedia of the Face, and                 Oppenheim of Vienna and Dr. Joseph Grünberg of Berlin were wisely invited
                                                                                                                                                                    Orthodontia, practically treated, both in 1904; also in 1904, a fine little       by Angle early in his courses, along with Fred Noyes, to give a biological
                                                                                                                                                                    volume of essays by Wallace, Irregularities of the Teeth (England); and the       tissue oriented background. Benno Lischer translated the superb Paul Simon
                                                                                                                                                                    textbook by Simean Guilford in 1905, Orthodontia. The well known Angle 7th        book, “Diagnosis of Dental Anomalies” from the original German in 1924. He
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                                                                                                                                                                    edition (actually the second editionthe first one was a commercial pamphlet       recognized the main concept of Simon's book, namely that the
                                                                                                                                                                    by a dental supply house, S.S. White and Company) initially issued in 1887        cephalometric relations of human dental anomalies are of fundamental
                                                                                                  Frederick B. Noyes and Harold Noyes
                                                                                                                                                                    and revised periodically by the company until Angle did his 6th edition in 1901   importance to an adequate clinical orthodontic diagnosis. Simon's
          Edward H. Angle                         Benno E. Lischer                                                                                                  and his famous volume-- was released in 1907, also by the same company            Gnathostatics, with its anthropologic orientation, stimulated B. Holly
                                                                                                                                                                    who made his patented appliances. Angle was not kind to his competition.          Broadbent to work with T. Wingate Todd, an eminent anthropologist in
                                                                                                                                                                    Germany and heavily revised and updated in 1910. It is a magnificent text         Cleveland, adapting a modified craniostat, implementing at least part of the
                                                                                                                                                                    with superb colored illustrations, that is all the more important, considering    Simon cephalometric (gnathostatic) analysis. Roentgenographic
                                                                                                                                                                    the impact of Functional Orthopedics on current orthodontic therapy. Angle        cephalometrics was to revolutionize orthodontic research and diagnosis.
                       He who is devoid of the power to                                                                                                             responded to the Herbst text in a form typical for his character. A letter to
                     forgive is devoid of the power to love.                                                                                                                                                                                          Broadbent's contributions cannot be overestimated. His own prodigious
                                                                                                                                                                    Herbst from Angle accused him of stealing from his book, even though Angle
                           Martin Luther King Jr                                                                                                                    disavowed functional jaw orthopedics FKO! Other texts from Germany at             efforts had a great impact on orthodontic diagnosis and craniofacial studies.
                                                                                                                                                                    that time include Jung (1906), Pfaff (second edition, 1908), and Korbitz, also    A close friend of Frederick B. Noyes, my mentor for 5 years, after his first
                                                                                                                                                                    a second edition, in 1911. A monthly journal exclusively devoted to               research at the Broadbent Bolton Foundation in Cleveland, Broadbent
                                                                                                                                                                    orthodontics/orthopedics was established in 1907, entitled Die Zeitschrift        installed the first private Broadbent-Bolton cephalometer in the Noyes
                                                                                                                                                                    fûr Zahnärztliche Orthopädie, which was the first journal in dentofacial          private office. Alan Brodie, Joseph Jarabak (Figure 18)(each one year) and I
                    “The best way to find yourself is to lose                                                                                                       orthopedics.
                      yourself in the service of others”.
                                                                                                                                                                                                                                                      (Figure 19 (for 5 years) were junior associates in the Noyes private practice,
                                                                                            Norman Kingsley                     John Nutting Farrar
                                                                                                                                                                    In France, the first journal is represented by Donogier (1895), Martinier         and in that order we were to use this equipment, while cephalometers at
                              Mahatma Gandhi                                                                                       (1839-1913)
                                                                                                                                                                    (1903) and Gaillard (1909). Spain joined the international team in 1909 with      the Broadbent Bolton Foundation in Cleveland, at the University of Illinois,
                                                                                                                                                                    a work by Subirana, Anomalies de la Occlusion dentaria y Ortodoncia.



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Northwestern University, Forsyth Infirmary, etc. were used to train a whole          school in Chicago, bringing in Alan Brodie from New Jersey to head the

                                                                                                                                                                            OPTIMAL POSTURE & POSITION IN
generation of researchers and clinicians.                                            orthodontic department in 1929. However. the universities of Michigan and
Under the aegis of Alan Brodie, the Angle Orthodontist was the main outlet           Pennsylvania awarded the first university advanced degrees in Orthodontics
for publication of myriad studies from both Illinois and other institutions in the   in 1925 and 1926, but Illinois, under the aegis of Noyes and Brodie, quickly
United States, Canada, and abroad. Unfortunately for orthodontics, Simon's
concepts of norm variability and three-dimensionality of dentofacial
                                                                                     became a premier training place for orthodontic specialists because of its
                                                                                     rigorous research and clinical programs and publication of so many of its              “PD DENTISTRY”
anomaliesconcepts we now recognize as the essence of orthodontic                     research studies in the Angle Orthodontist,
                                                                                     starting in 1931. A strong relationship with
diagnosiswere again sacrificed on the alter of personal antipathies and




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                                                                                                                                                                                                                                                                         be
                                                                                     B. Holly Broadbent of Cleveland existed. The
prejudices. The editors of the American Journal of the American
                                                                                     very first article in the Angle Orthodontist
Association of Orthodontia (American Society of Orthodontics after 1933)
                                                                                     was by Broadbent on radiographic
and the Angle Orthodontist were Angle disciples and would not publish
                                                                                     cephalometrics! Truly a landmark
material from Benno Lischer and his students. What a tragic loss!
                                                                                     article!How fortunate I was to be asked to
                                                                                     join Dr. Fred Noyes in private practice after
                                                                                     finishing my orthodontic graduate training
                                                                                     under his son, Harold Judd Noyes at                                              It is well known that most                                                            n early supporter of Angle, Calvin Case later became concerned with the




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                                                                                     Northwestern! Noyes was 82 and I was 28.                                         of the dentists around the                                                       total rejection of “extraction of teeth at any cost” and the commercialism by
                                                                                     His office was a mecca for national and                                          world are suffering during                                                       the Angle system proponents, thereby incurring the wrath of Angle, and his
                                                                                     international orthodontic colleagues, with                                       patient treatment due to                                                         disciples. The celebrated Case/Dewey debate in 1911 settled no issues, but
                                                                                     Dr. Broadbent and Dr. Silas Kloehn of                  Albert Ketcham            musculoskeletal disorders
                                                                                     headgear-growth guidance fame being the most frequent visitors. During                                                                                            further divided the Angle group from the rest of the American orthodontists.
                                                                                                                                                                      (MSD).                                                                           Anna Hopkins, long time secretary from the early 1890s, later his wife after
                                                                                     the five years I was there, I traced many thousands of cephalometric
                                                                                     headfilms, both frontal and lateral views. After a day with patients, we would   Do you know that there is a                                                      their marriage in 1908, wrote most of the Angle correspondence for him,
                                                                                     often sit in Dr. Noyes private office and he would reflect on his experiences.   better way to perform                                                            actually graduating from the University of Iowa in 1904 as a dentist. Martin
                                                                                     One afternoon, after we had pinned in our last ribbon arch, Dr. Noyes was in     dentistry? It is based on the                                                    Dewey was a student of Angle, but like so many of these early followers, he
                      1949. Angle Society Meeting                                    an expansive mood. I mentioned to him that Lischer had once said that he         use of the "0 Concept"*                                                          deviated from the Angle dictum, formed his own Dewey School of
                                                                                     doubted that Angle knew much about the histologic changes associated             (“Zero Concept ”) and                           Fig. 1                           Orthodontia and wrote a very good orthodontic textbook. But the bitter
                                                                                     with tooth movement. Noyes thought a while and then responded, “Well             "proprioceptive                                                                  rivalry and personal attacks lasted a lifetime.
                                                                                     that may or may not be true. But Angle was a geniusa mechanical genius.          derivation"* (“pd”) for health and health care which is already applied in
                                                                                                                                                                      several countries including India.                                               It certainly is true that the early orthodontic pioneers in America indulged in
                                                                                     He started out as a machinist. He didn't see the need for cluttering his mind
                                                                                                                                                                                                                                                       considerable personal invective, as they sought to establish their own pre-
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                                                                                                                                                                                                                   or
                                                                                     with lots of miscellaneous facts that others could present. When he needed       It is the result of the life-long pursuit of Daryl Beach - an American DMD and   eminence and priority of claims for specific “treatment rationale and
                                                                                     a histologist, he knew where to get one. When he needed an artist, he turned     researcher residing in Japan. It all started in the 1960s when he wanted to
                                                                                     to a damned good one, Edmund Wuerpel!” This resonated well with me,                                                                                               systems.” Orthodontics was a dogma, a religion. Ray Begg of Australia, a
                                                                                                                                                                      find a natural comfortable way to practice dentistry.
                                                                                     because, serrendipitously, I had taken a course in art appreciation from Dr.                                                                                      student of Angle early on, told an American orthodontic meeting in
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                                                                                     Wuerpel, Dean of the School of Art & Architecture at Washington University       His main concern was to consciously derive human-centered working                Washington D.C in 1954, “This is the way to do it! If you vary it one iota from
                                                                                     in St. Louis, in my pre-dental training in 1935! Little did I know of his        conditions with minimum body tension which allow maximal finger-forearm          my technique, I've tried it already and it failed!”
                                                                                     importance earlier in orthodontics!                                              control to achieve the most precise desired and reproducible outcomes.
                                                                                                                                                                                                                                                       Those historical orthodontic building blocks at the turn of century include the
                                                                                                                                                                      Naturally he came to redesign the dental equipment through global                work of Walkoff, Die Unregelungen mässigkeiten in den Zahnstellungen und




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            Martin Dewey                          .
                                                 P Raymond Begg                                                                                                       standards.                                                                       Ihre Behandlung which was published in 1891; a pretentious volume by
Angle established the American Association of Orthodontics in 1901, after                                                                                             In this first article we will focus on the ergonomic aspects.                    Colyer (1900), Irregularities of theTeeth (England) ; an excellent text by
resigning from St. Louis University and opening his own private school. He                                                                                                                                                                             MacDowell, of Northwestern University in Chicago, in 1901, the works of
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was joined and assisted largely in the formation by former students and                                                                                                                                                                                Knapp and of Jackson, Orthodontia and Orthopedia of the Face, and
associates many of whom would become leaders in the field of orthodontics.                                                                                                                                                                             Orthodontia, practically treated, both in 1904; also in 1904, a fine little
He attracted a coterie of outstanding students from the United States and                                                                                                                                                                              volume of essays by Wallace, Irregularities of the Teeth (England); and the
Canada, for his first 4 week intensive “Angle course”, held in his private                                                                                                                                                                             textbook by Simean Guilford in 1905, Orthodontia. The well known Angle 7th
office. One of his early teachers, starting in 1904, was Frederick Bogue                                                                                                                                                                               edition (actually the second editionthe first one was a commercial pamphlet
Noyes, of Chicago, Professor of Histology at Northwestern University and                                                                                                                                                                               by a dental supply house, S.S. White and Company) initially issued in 1887
son of Edmund Noyes, who was Dean of the Northwestern Dental School.                                                                                                                                                                                   and revised periodically by the company until Angle did his 6th edition in 1901
                                                                                             B. Holly Broadbent                      Allan G. Brodie
Fred Noyes also took the Angle clinical course in 1907 and limited his private                                                                                                                                                                         and his famous volume-- was released in 1907, also by the same company
practice to orthodontics. His book oral histology in 1914 was one of the first                                                                                                                                                                         who made his patented appliances. Angle was not kind to his competition.
in this field in America and became the standard book in American dental                                                                                                                                                                               Do you know that there is a better way to perform dentistry? It is based on
                                                                                                                                                                                         Fig. 2                             Fig. 3
schools. Noyes inculcated a sense of tissue consciousness in those who                                                                                                                                                                                 the use of the "0 Concept"* (“Zero Concept”) and "proprioceptive
took the Angle course, along with lectures from the eminent Albin                                                                                                     1. THE GLOBAL CONCEPT                                                            derivation"* (“pd”) for health and health care which is already applied in
Oppenheim from Vienna and Joseph Grünberg of Berlin.. Noyes was always                                                                                                The “Concept of       Zero” or “0 Concept” originated from India: it is          several countries including India.
grateful to Dr. Angle for asking him to teach tissue response to tooth                                                                                                UNIVERSAL.                                                                       It is the result of the life-long pursuit of Daryl Beach - an American DMD and
movement, Oppenheim from Vienna and Joseph Grünberg of Berlin.. Noyes
                                                                                                                                                                      It is a reasoned and effective knowledge.                                        researcher residing in Japan. It all started in the 1960s when he wanted to
was always grateful to Dr. Angle for asking him to teach tissue response to                                                                                                                                                                            find a natural comfortable way to practice dentistry.
tooth movement, even though it was a proprietary school where most                                                                                                    It is well known that most of the dentists around the world are suffering
students came to learn the “how” and not the “why” of orthodontics. Dr.                                                                                               during patient treatment due to musculoskeletal disorders (MSD).
Noyes later moved to the University of Illinois and became dean of the dental                    Joseph Jarabak                      Edward Angle




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His main concern was to consciously derive human-centered working                 Operating fingers at “heart level”          best finger control and best views
conditions with minimum body tension which allow maximal finger-forearm
control to achieve the most precise desired and reproducible outcomes.
                                                                                  3. THE PD DENTIST
                                                                                  operates with pd unit and pd instrument sitting behind the head of the
                                                                                                                                                                            ORTHODONTIC MANAGEMENT
Naturally he came to redesign the dental equipment through global
standards.
                                                                                  patient.
                                                                                  The seat height is set by proprioceptive derivation to allow best performance
                                                                                                                                                                            OF MENTALLY CHALLENGED
In this first article we will focus on the ergonomic aspects.
                                                                                                                                                                            PATIENTS
                                                                                  at the 0 Point.




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The numeral "0" represents symbolically the absence, the emptiness or the         From this optimal position, the operator should be able to orbit freely around
wholeness (universe,                                                              the patient’s head from 2 o’clock to 10 o’clock, unobstructed by any objects                                                                                                               Prof. (Dr.) Ashutosh Shetty Professor,
                                                                                  or by the assistant.                                                                                                                                                    Department of Orthodontics and Dentofacial Orthopedics
earth, human being), as well as the order, the origin, the goal, the optimal
                                                                                                                                                                                                                                                                A. B. Shetty Memorial Institute of Dental Sciences,
condition or the equilibrium, the scale and measure, etc...                       An optimal body balanced position and posture with the operating fingers at                                                                                                                   Deralakatte, Mangalore, Karnataka
Let“0” represent symbolically a perfect state of health. Health is the goal. “0   “heart level = minimum body tension ? maximum finger control.
Health” is the goal of health care or absence of need for care.
"0" is the basic reference for easy codification and classification of




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information as it is universally accepted.                                                                                                                            Medline Plus a service of U.S. National Library of Medicine and the National             Exams and Tests
2. THE ZERO (0) POINT AND PROPRIOCEPTIVE DERIVATION (PD):                                                                                                             Institutes of Health defines Mental retardation as a condition diagnosed                 An assessment of age-appropriate adaptive behaviors can be made using
? USE OF THE BODY
OPTIMUM                                                                                                                                                               before age 18 that includes below-average general intellectual function, and             developmental screening tests. The failure to achieve developmental
                                                                                                                                                                      a lack of the skills necessary for daily living.                                         milestones suggests mental retardation.
Fig. 2 and 3: The Zero Point                                                                          Fig. 6                          Fig. 7
                                                                                                                                                                      American Association on Intellectual and Developmental Disabilities                      The following may be signs of mental retardation:
A human-centered approach and simplicity are the keys. Applying this              Fig. 6 and 7: Optimal body balanced posture and position.
                                                                                                                                                                      (AAIDD) defines Intellectual disability as a disability characterized by                 •        Abnormal Denver developmental screening test
Concept gives us the key to a universal method which is revolutionary in          4. THE PATIENT                                                                      significant limitations both in intellectual functioning (reasoning, learning,           •        Adaptive behavior score below average
many ways.
                                                                                  is lying for treatment at full rest position on a horizontal human support (no      problem solving) and in adaptive behaviour, which covers a range of everyday             •        Development way below that of peers
Why it is universal? Because it is based on human-centered standard -             tilting backrest). Why?                                                             social and practical skills. This disability originates before the age of 18.
called “proprioception” (meaning "self-perception" from Latin) or more                                                                                                                                                                                         •        Intelligence quotient (IQ) score below 70 on a standardized IQ test
                                                                                  This positioning allows the patient's mouth in a predictable position               The American Association on Mental Retardation changed its name in 2007
precisely “proprioceptive derivation” (pd) ? which is common to all human                                                                                                                                                                                      Possible Complications
                                                                                  regardless of the patient's size and                                                to the American Association on Intellectual and Developmental Disabilities
beings.                                                                           provides the best access to the mouth.                                                                                                                                       •        Inability to care for self
                                                                                                                                                                      Mentally challenged - a euphemism for mentally retarded or disabled.
                                                          &




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                                                                                                                                                                                                                   or
Indeed the human body has an inborn wisdom which is expressed when it is                                                                                                                                                                                       •        Inability to interact with others appropriately
                                                                                  5. OPTIMIZED TREATMENT
in perfect balance (“0 condition”).                                                                                                                                   It is crucial that ‘mental retardation’ and ‘intellectual disability’ should be          •        Social isolation
                                                                                  AREA (6 M2)
                                                                                                                                                                      precisely synonymous in definition and in all related classification because
This inborn physical perception is the self-awareness of the position and         with a pd unit and cabinet:                                                                                                                                                  The more attractive one’s external appearance, the greater the likelihood of
                                                                                                                                                                      current federal and state laws contain the term ‘mental retardation.                     receiving positive peer appraisal, which supports a positive internal self-
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movements within our own body. It is not a question of culture but is
                                                                                  The area is an open space where the                                                 Also, the term ‘mental retardation’ is used for citizenship and legal status,            (Jacobson, 1984). The face is the primary focus of identification and a rich
characteristic of all human beings ? a common heritage.
                                                                                  pd unit is the centrepiece (the                                                     civil and criminal justice, early care and education, training and employment,           source of non-verbal information (Ekman, 1978), and first impressions are of
Developing the self-awareness of the body enhances the manual skill,              machinery is hidden inside the unit)                                                                                                                                         primary importance.
                                                                                                                                                                      income support, health care, and housing and zoning.
allowing the easiest movement with the minimum tension and maximum                allowing free movements of the




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                                                                                                                                                                      Mental retardation affects about 1 - 3% of the population. There are many                Children with physical or mental disability usually have a different facial
precision.                                                                        operator and featuring:
                                                                                                                                                Fig. 8                causes of mental retardation, but doctors find a specific reason in only 25% of          appearance, which generates a far-from-desirable first impression. The high
Complex tasks - like those involved in dentistry ? can be done in best body       •           fixed horizontal human support,                                                                                                                                  prevalence of malocclusion among these children (Oreland et al., 1987),
                                                                                                                                                                      cases.
conditions with the greatest accuracy and precision, avoiding therefore                                                                                                                                                                                        poses an additional obstacle to social acceptance, from an aesthetic point of
                                                                                  •     fixed tray,
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muscular-skeletal disorders.                                                                                                                                          A family may suspect mental retardation if the child's motor skills, language            view, but also because it may compromise all aspects of oral function
                                                                                  •     fixed lights (rising up and down with the unit),                              skills, and self-help skills do not seem to be developing, or are developing at a
The most comfortable position of the sitting operator with associated best                                                                                                                                                                                     Malocclusions occur more often in physically and/or mentally handicapped
views while performing precise tasks is determined by masked-eye tests            •     foot controller for all functions (no hand switches),                         far slower rate than the child's peers. Failure to adapt (adjust to new                  children than in healthy children. Specific handicapped groups, such as
using the proprioceptive (feel-based) senses of the body ? with no                •     powerful vacuum avoiding spittoon,                                            situations) normally and grow intellectually may become apparent early in a              those with Down’s syndrome or cerebral palsy, have been associated with
                                                                                                                                                                      child's life. In the case of mild retardation, these failures may not become             increased frequencies of particular dental features (Cohen and Winer
preconceptions or defense from past habits: the forearm long axis is close to     •     cabinet with wash basin (direct access for dentist and assistant).
                                                                                                                                                                      recognizable until school age or later.                                                  1965; Franklin et al.,1996).
45 degrees and the average focal distance between 23-24cm in the sagittal
                                                                                  6. THE BENEFITS                                                                                                                                                              Oreland et al(1987) found a higher prevalence of dental malocclusion in
plane of the chest at heart level.                                                                                                                                    The degree of impairment from mental retardation varies widely, from
                                                                                  •     for patient: safer and better care,                                           profoundly impaired to mild or borderline retardation. Less emphasis is now              the severely mentally retarded compared with physically handicapped
This location is called "0 Point" for the operator.                                                                                                                                                                                                            children, and concluded that the mental condition is more important for the
                                                                                  •     for care providers: least body tension and skeletal-muscular                  placed on the degree of retardation and more on the amount of intervention
“Pd” is the global principle for optimum use of operators' fingers with                                                                                                                                                                                        orthodontic status than the medical diagnosis.1
                                                                                        health. Working posture that can be maintained for a long time                and care needed for daily life.
associated views of operating points from which working posture & position              without fatigue,                                                                                                                                                       Owen and Graber (1974) classified handicapped children as mildly,
of the operators and the whole dental clinic can be derived.                                                                                                          Symptoms                                                                                 moderately, and severely handicapped. They based the possible benefits
                                                                                  A dentist can perform his job in a healthy way during working life time.                                                                                                     from orthodontic treatment, the exact treatment plan, and the management
                                                                                                                                                                      •        Continued infant-like behavior
                                                                                  This Global Concept provides the easiest way and the optimum conditions to
                                                                                                                                                                      •        Decreased learning ability                                                      modality on the physical and mental characteristics of each category2.
                                                                                  maintain high quality of care with the highest control of fingers for the benefit                                                                                            In the early years of the 20th century, individuals with mental retardation
                                                                                  of the patients all around the world.                                               •        Failure to meet the markers of intellectual development
                                                                                                                                                                                                                                                               were generally isolated rather than encouraged to lead fulfilling and healthy
                                                                                                                          For more information, please contact:       •        Inability to meet educational demands at school                                 lives. The insensitivity towards individuals with mental retardation has
                                                                                                            Dr. Jacques VERRE: jacverre@gmail.com (France)            •        Lack of curiosity                                                               ranged from abject treatment less than human, to recognition as rightful
                                                                                                                                                                                                                                                               members of society but with practices that continue to restrict integration
                                                                                                      Dr. Wolf NEDDERMEYER: wolfn@hotmail.com (Germany)                                                                                                        into the mainstream of society3.
                       Fig. 4                         Fig. 5


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Studies indicate that the main benefit of orthodontic treatment to the patient     Parents expected the treatment to improve the child’s quality of life and their    Selecting the Treatment Modality                                                   1. Realistic Treatment Goals
may be improved dental aesthetics and psychosocial well-being. The                 acceptance within society. Parents consider that the outcome of orthodontic        Communication is vital for the education of orthodontic special needs              When conditions are compromised by the existence of adverse factors, then
continuing deinstitutionalization process of persons with mental retardation       treatment for their child would reflect positively on their own social status.     patients, since orthodontic treatment is a multivisit modality of extended         treatment must be redirected toward more limited goals, more suited to the
is bringing the orthodontist into contact with those in need of special health                                                                                                                                                                           circumstances that the patient’s condition dictates. Each child has his or her
                                                                                   Behavior Management                                                                duration.For those patients who have difficulties in communication and a
services. Such trends suggest a possible increase in demand for dental                                                                                                                                                                                   own achievable optimum, which needs to be assessed by the clinician, who
                                                                                   The orthodontist must approach these patients with understanding and               relative inability to cooperate, we can offer conscious sedation, deep
services including orthodontic care by handicapped persons.
                                                                                                                                                                      intravenous sedation, or the use of general anaesthesia.                           must then apply treatment procedures appropriate for the child.
Jackson (1967) felt that children with learning disability should not be           compassion and aim to gain their trust. Treating these patients is enormously
                                                                                   challenging.                                                                       The choice of the technique used should be the simplest and safest available       2. How to take Records
discounted merely because an ‘ideal’ orthodontic result was not possible.




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For these patients, the aims of orthodontic treatment may need to be                                                                                                  that is appropriate for the needs of the specific task to be performed for each    An adequate clinical examination is possible by using behaviour modification
                                                                                   They require more chair side time, an increased number of appointments,
modified from ‘ideal’ but orthodontic treatment may offer an aesthetic                                                                                                individual patient. The main reason for the need for sedation does not relate      techniques alone, problems will often arise when attempting to take
                                                                                   and treating them in a regular orthodontic office and among healthy patients
improvement and hence enhanced social acceptance.4                                                                                                                    to pain, but rather to achieving a submissive or motionless state in the           impressions or radiographs. Accordingly, alternative adjunctive modalities
                                                                                   is problematic, since they disturb the regular schedule times.                     patient, for an extended period of time.
Since 1974 patient management has changed dramatically and a wide range                                                                                                                                                                                  must be used, preferably in a step-by-step approach, from nitrous oxide
                                                                                   General Treatment Principles                                                       It is essential to establish that, for most routine visits for appliance           conscious sedation alone, or combined with other pharmacological agents.
of pharmaceutical and behavioural techniques are available today that
simplify the control of adverse behavioural patterns. As a result, it has been     The aim of the pretreatment visits is three-fold:                                  adjustment, the use of behaviour management techniques, such as “Tell,             When considering radiographs, the panoramic view is considered to be the
possible to considerably narrow the chasm separating treatment need from           1. To raise the patient’s level of confidence in the dental environment,           Show, and Do,” behavior modification and positive and negative                     basic overall scan that may be used for the orthodontic assessment.
treatment access and delivery.                                                                                                                                        reinforcement is adequate to achieve the goals of the respective visits. It        However, it requires minimal patient cooperation in sitting still during the




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                                                                                   2. To assess the patient’s and parent’s compliance in dental homecare, and
Over the past 20 years or so, both the absolute number and proportion of                                                                                              then remains for a decision to be made as to which of the available                rotation of the tube of the panoramic machine. Restricting a
special needs children in society has increased, despite prenatal diagnostic       3. To evaluate the expected degree of cooperation that will finally be             supplementary modalities is suitable for poorly tolerated procedures.              nonunderstanding and frightened child in a cephalostat or in a panoramic
techniques and the improvement in prenatal identification of congenital            forthcoming.                                                                                                                                                          machine will often increase their fear and even generate panic.
                                                                                                                                                                      Conscious sedation is a pharmacologically induced state of relaxation in
anomalies.                                                                         Oral hygiene is perhaps the most crucial factor that dictates whether or not       which the patient remains conscious. It is aimed at changing the patient’s         There are several other alternative radiographic views, such as multiple
The main reasons are:                                                              orthodontic treatment should be provided for the particular patient.               mood and degree of compliance throughout the dental treatment,                     intraoral periapical views or lateral extraoral jaw views, where the film or
1. Sophisticated medical care, both perinatal and adult, that has                  Tooth brushing is not usually practiced by special needs children and, even        facilitating acceptance of the procedure. This modality is used as an adjunct      cassette may be held by a suitably protected parent during the x-ray
increased the survival rate of newborns, but also their overall life expectancy.                                                                                      to the regular behaviour modification techniques, only when the latter have        exposure. In certain instances, one can refer the patient for a computed
                                                                                   when it is, considerable collections of food from recent meals may be seen in
                                                                                                                                                                      failed to permit therapeutic access.                                               tomographic (CT) scan performed under sedation in the hospital. However,
2. Given the enlightened attitude of society today, changing social                several areas of the mouth, including around the teeth.
                                                                                                                                                                                                                                                         the latter is rarely warranted.
policies and legislation, many more special needs children are seen as             A lessened activity of the oral musculature, common in several debilitating        It may be elicited by the administration of drugs through
integral parts of their own families, with adoptive families or in sheltered                                                                                                                                                                             Whenever sedation or GA are needed for taking records, the aim should be to
                                                                                   conditions, and a lack of manual dexterity may contribute significantly to the     •     Inhalation (nitrous oxide and oxygen),
housing and thus far more visible in general, whereas three decades ago                                                                                                                                                                                  combine them with other needed dental procedures (pedodontic,
                                                                                   stagnation.                                                                        •     Transmucosally via nasal drops (Midazolam),                                  orthodontic, oral surgery) to limit to a minimum the number of such
they were largely housed in institutions.
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                                                                                                                                                                                                                  or
                                                                                   The first step is to educate the parent and, whenever possible, the child to       •     Orally (chloralhydrate,Diazepam,Midazolam)or                                 procedures.
With their higher public profile, the present-day affluent society there has
been a general improvement in quality of life of these children that, in turn,     recognize plaque and gingival inflammation and to teach them the correct                                                                                              3. Treatment Provided in Modules
                                                                                                                                                                      •     Intravenously (Propofol).
expresses itself in an increased demand for aesthetics and normal function.        way to brush the teeth.
                                                                                                                                                                      Although conscious sedation is relatively free of pharmacokinetic and              It is wise to establish reasonable goals on a modular basis, and to reassess
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The aim is acceptance into society, including the chance for employment            While the child may be prepared to improve their ways, it is made clear to the     cardiovascular complications and is relatively inexpensive, its limited            them after each stage, being prepared to make the necessary changes if
toward self-sufficiency. Concern for facial appearance has become an item          parent that they must undertake the overall responsibility of achieving a          sedation potency makes it largely inadequate for the more demanding long           needed based on the treatment experience with the previous stage, for the
for discussion among parents and this has generated a demand for                   mouth that is both cleaned regularly and that may become inflammation-             and complicated procedures, such as orthodontic bracket bonding.                   particular disabled individual.
orthodontic treatment6                                                             free.                                                                              Accordingly, general anesthesia has been employed for the more involved            4. Simplifying Treatment




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Therapeutic access to these patients is impeded by the following several           This will generally mean that the parent must brush the child’s teeth, since       orthodontic procedures. GA requires the patient to be hospitalized and the         From the orthodontist’s point of view, fixed appliances are more difficult to
specific obstacles:                                                                the child may not be able to reach the required standard alone. Parental tooth     procedure performed in a specialized operating theater room, with all the          place, especially in these children, because they require specific conditions,
1. General behaviour is often problematic because of reduced                       brushing helps to overcome the child’s defence reaction, apprehension, and,        attendant potential intra-operative or postoperative respiratory and               such as the need for the patient to sit still for long periods of time to enable
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understanding and increased apprehension, short attention span, and                often, the gag reflex. This encourages the child to subsequently surrender         cardiovascular complications. These complications increase the potential           the precise positioning of the brackets and with complete dryness of the
limited tolerance.                                                                 control of the oral environment to professional intrusion into the oral cavity.    morbidity and the overall cost.                                                    teeth. Thus, sedation or general anesthesia is sometimes needed to
2. Uncontrolled limb and head movements and an inability to sit still                                                                                                 Intravenous (IV) deep sedation is much more suited than GA to the relatively       facilitate their placement, which is not the case with removable appliances.
                                                                                   Tentative Treatment Plan
making it difficult even to seat the child in the dental chair.                                                                                                       trivial and painless procedures that are specific to orthodontics, insofar as it   It is recommended to extend the use of removable appliances, with or
                                                                                   In routine orthodontics with healthy children, our treatment plan is drawn up
3. Level of cooperation during treatment is usually significantly impaired.                                                                                           does not require an operating theater room and hospitalization, but can be         without extraoral headgear incorporated, and limit the period of fixed
                                                                                   after evaluating the patient clinically, examining plaster casts, studying         performed by the anaesthesiologist in the orthodontist’s office. Induction
4. Exaggerated gag reflex, apparently related to dental/medical phobia.                                                                                                                                                                                  appliance wear. Orthodontic appliances with a longer range of action,
                                                                                   clinical photographs, radiographs, and the cephalometric analysis. The steps       and recovery are rapid; a safe level of sedation is easily achieved, with few      requiring less frequent visits, are to be preferred.
5. Markedly increased incidence of drooling in many cases.                         taken to produce these important aids are very simple and largely trouble-         side effects, and with sensible use of safety measures, the risk of aspiration
                                                                                   free.                                                                                                                                                                 5. Adapting Treatment to Sedation/GA
These factors contribute to significant difficulty in performing otherwise                                                                                            and other medical emergencies is extremely small. Vital reflexes are
routine procedures, such as impression taking and intraoral radiography.           However, in an apprehensive or antagonistic special needs patient, some of         maintained throughout, intubation is superfluous, and complications thereby        Aspiration is one of the most dangerous sequellae of any procedure that
                                                                                                                                                                      reduced. Given its convenience and availability, and the fact that it is           involves a partial or total loss of the patient’s protective reflexes.
Accordingly, successful treatment delivery often requires different                these records may not be achievable without some form of pharmacological
behaviour management approaches, starting from simple behaviour                    assistance and others may never be obtainable. Therefore, a general                conducted in the regular orthodontic office environment, patient acceptance        Due care and the application of specific safety measures are essential to
modification techniques through conscious and deep sedation to general             direction of treatment is sometimes determined on the basis of a clinical          is increased, more complex procedures become achievable, and other                 prevent debris, water, saliva, blood, or orthodontic materials entering the
anaesthesia.                                                                       examination only, and full diagnostic records are acquired subsequently, as        nonorthodontic tasks may be incorporated into the session, simultaneously.         airway and producing laryngospasm or possible infection of the trachea or
                                                                                                                                                                                                                                                         bronchi.
Motivation and Expectation                                                         the initial items in the first sedation session. The tentative treatment plan is   Adapting Orthodontics to the Special Needs Child
As with healthy children, improvement in facial appearance is the main             confirmed or altered and actual treatment procedures, such as band                                                                                                    In specific disability groups (eg, those with cerebral palsy or muscular
                                                                                                                                                                      In the unusual circumstances presented by a special needs child, standard
motivating factor for treatment. However, among special needs children, the        placement, extractions, and dental fillings, are performed at the same                                                                                                dystrophy), the cough reflex is impaired and there is an increased danger of
                                                                                                                                                                      orthodontic protocols must be adapted to suit the individual problems seen
proportion of parents whose declared aim was improvement in oral health            session.                                                                                                                                                              aspiration. The use of a rubber dam is recommended as a useful aid and an
                                                                                                                                                                      in the patient.
and function was markedly increased, presumably due to a higher frequency                                                                                                                                                                                effective safeguard in bracket bonding during GA.
of impairment.


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An oropharyngeal pack is mandatory when rubber dam placement is                    Posttreatment Satisfaction
impossible (for impression taking, band fitting, or appliance cementation
such as palatal/lingual arches).
                                                                                   Most parents of special needs patients noted satisfaction with the results of
                                                                                   orthodontic treatment. They reported not only positive facial/dental
                                                                                                                                                                          COMPOSITE RESIN CURING
                                                                                                                                                                          STRATEGIES
Indirect bonding of brackets is faster, reduces sedation time, and minimizes       changes, but also improvement in oral functions, the swallowing pattern, the
the possibility of aspiration. This does not eliminate the need for an             related drooling, speech, and even mastication. Additionally, they noted
oropharyngeal pack, which is needed to block fluids and small particles            that, in those children who were aware of the improved appearance, this
(e.g.brackets) from entering the upper respiratory tract.                          resulted in associated improvement in esthetic self-satisfaction and self-




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Since the sedated patient cannot bite down on a bite stick, it is prudent to fit   confidence.                                                                                                                                                                                     Dr. Yadav Chakravarthy
molar bands before the sedation or GA session, wherever possible.                  Conclusion                                                                                                                                                                                          Associate Professor,
High quality and accurate bonding must be assured to avoid the need for            A need exists for firm guidelines that will be helpful in predicting the                                                                                             Department Of Conservative Dentistry & Endodontics
subsequent rebonding without sedation.                                             orthodontic management needs of disabled children, in the light of the                                                                                         Vinayaka Missions Shankarachariyar Dental College, Salem.
                                                                                   unsuitability of existing classifications used in paedodontic practice. The                                                                                         Correspondence Email: yadavchakravarthy@gmail.com
The most reliable and proven bonding materials should be employed.
                                                                                   community and the health organizations, in general, and the orthodontic                                                                                                           Ph: 09894479609. Fax: (0427) 2477318.
Sandblasting is recommended, but only with a well-placed rubber dam and
high-power suction to prevent the aspiration of the fine aluminum oxide            profession, in particular, should aim at improving the social welfare of this
                                                                                   group of patients, and




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powder.
Recently developed primers that enhance the strength of bonding even in            instruct more professionals in methods of care for the disabled, in order to    INTRODUCTION:                                                                         UV LIGHT CURING UNIT:
wet environments are particularly useful in patients with excessive                facilitate their accessibility to orthodontic treatment.
                                                                                                                                                                   The purpose of any unit in practice is to improve the quality of treatment and        The First light activated system had been initiated by a UV light curing unit
salivation. These, together with the use of antisialogogue drugs and special       References:                                                                     facilitate the procedure for both the operator and the patient.                       (Pic (2)), which allows the operator to complete both insertion of the
devices to maintain dryness, such as the Dry system (are also helpful.             1. Orthodontic treatment for disabled children: motivation, expectation, and                                                                                          composite resin and sufficient time for contouring according to tooth
                                                                                                                                                                   The growing popularity of photopolymerization systems for dental
6. Relapse and Retention                                                           satisfaction: Adrian Becker, Joseph Shapira and Stella Chaushu: European        restoration has resulted in light curing units with various features being            structure16. But however, it cures only a few layers and is time consuming.
Removable retainers will hold the alignment of teeth within the maxillary or       Journal of Orthodontics 22 (2000) 151-158.                                      developed. The clinician can now choose from a variety of light curing units          QUARTZ TUNGSTEN HALOGEN CURING UNIT:
mandibular arch, but cooperation must be assured. Where this may be in             2. Behaviour management needs for the orthodontic treatment of children         for photopolymerization of light activated dental resins, such as                     Introduced in the 1970’s , Quartz tungsten halogen (Pic (3)) is the most
doubt, bonded lingual splints are preferred, even though this may involve a        with disabilities; Stella Chaushu and Adrian Becker , European Journal of       Conventional Quartz Tungsten Halogen, Laser, Plasma Arc, Light Emitting               common light curing source in today’s dental practice. Most commonly
further sedation session for its reliable placement.                               Orthodontics 22 (2000) 143-149.                                                 Diode (LED), etc.                                                                     referred to as halogen lights, they are excellent for curing resins and have
Failures                                                                           3. Malocclusion and Orthodontic Treatment Need of Mentally Handicapped          Most light curing units used in dental offices deliver inadequate light               become a real workhorse in dentistry.
                                                                                   Children in Lagos, Nigeria Pesq Bras Odontoped Clin Integr, João Pessoa,        intensity 17, 19. This problem has been attributed to several factors,                Halogen lights produce a blue light by passing current through tungsten
Failures occur in every orthodontic practice, for a variety of reasons, most of
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                                                                                                                                                                                                                 or
                                                                                                                                                                   including fluctuations in line voltage, deterioration of the light bulb,
which are also present among the special needs population. We may see              9(1):7-11, jan./abr. 2009                                                                                                                                             filament in a quartz bulb (410nm – 500nm of the visible spectrum) that
                                                                                                                                                                   deterioration of the reflector or filter, contamination of the light guide, effects
specific adverse circumstances, such as an aberrant growth pattern,                4. The Orthodontic Management of Patients with Profound Learning                of disinfection procedures on the transmission of light through the light guide       contains halogen gas. The light is reflected and then goes through filters
                                                                                   Disability: Chadwick and. Asher McDade, British Journal of                      and malfunction of the photoconductive fibers in the light guide12.                   producing a broad wavelength of light to cure resins. Due to the broad
progressive myopathy, a sudden and unexpected change in the
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                                                                                   Orthodontics/Vol.24/1997/117-125                                                                                                                                      wavelength produced, halogen lights also produce some extra heat30.
environment, deterioration in the child’s general health or deterioration in                                                                                       If a light activated resin restoration does not receive sufficient total energy at
behavior (noncompliance with oral hygiene or treatment instructions)               5. Orthodontic Treatment for Disabled Children - A Survey of Patient and        the correct wavelengths from the light curing unit, the effects of wear may
associated with puberty, which prejudices the chances of achieving a good          Appliance Management ; Adrian Becker, Josef Shapira, Stella Chaushu:            be increased 14,24. Greater breakdown at the margins of the restoration14,
and long-lasting orthodontic result. For this reason, the recommendation           Journal of Orthodontics/Vol. 28/2001/39-44.                                     decreased bond strength between the tooth and the restoration22, greater




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regarding modular treatment increments has merit.                                  6. Orthodontic treatment for the special needs child, Adrian Becker, Stella     cytotoxicity5,27, reduced
                                                                                   Chaushu and Joseph Shapira; Semin Orthod 10:281-292, 2004.                      hardness 3,22,28, lower dynamic elastic modulus, etc 20.
                                                                                                                                                                   The amount of light energy received at the top and the bottom of a resin
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                                                                                                                                                                   composite restoration are affected by many variables, such as power
                                                                                                                                                                   density from the curing light, duration of exposure, design of the light guide,
                                                                                                                                                                   distance from the tip of the light guide to the restoration, the composition,
                                                                                                                                                                   thickness, shade and opacity of the composite resin1, 2,4,6,10,11,20,23,28.
                                                                                                                                                                   CHEMICAL CURING METHOD:                                                                                                                  (Pic (2))
                                                                                                                                                                   The composite resins that were used earlier, were cured by a chemical
                                                                                                                                                                   method, which consists of a two paste system i.e., a Base and a Catalyst                             (Pic (1))
                                                                                                                                                                   (pic(1)). Benzyl peroxide acts as a Base and Tertiary amine as a Catalyst.
                                                                                                                                                                   Once this amine and benzyl peroxide is mixed, it produces free radicals
                                                                                                                                                                   which initiate the chemical curing in composite resins16.
                                                                                                                                                                   Chemical curing method has a drawback that it is impossible to avoid
                                                                                                                                                                   incorporating air bubbles into the mix. These air bubbles contain oxygen that
                                                                                                                                                                   causes oxygen inhibition during polymerization which leads to failure of the
                                                                                                                                                                   resin material. Another drawback is that the operator has no control over
                                                                                                                                                                   working time16.
                                                                                                                                                                   To overcome the drawbacks of chemical curing composite resins, the light
                                                                                                                                                                   curing composites were introduced wherein the camphoroquinone acts as a
                                                                                                                                                                   photo initiator component of light curing composite resins.
                                                                                                                                                                                                                                                                                           (Pic (3))




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This light falls in the absorption spectrum of the camphoroquinone photo              This improves patient comfort and reduces the time needed to complete the          COMPONENTS OF LED UNIT:                                                            CONCLUSION:
initiator (400 – 500nm), which on absorption gets excited and combines                procedure. Plasma Arc Curing Lights are very expensive, cause rapid                1.    Glare protection                                                             The first generation composites that were cured by a chemically activated
with an amine accelerator to generate free radicals for polymerization. The           polymerization and increase polymerize shrinkage 30.                                                                                                                  polymerization process underwent oxygen inhibition and the polymerization
Resin exposure time to this light varies between 20 – 60sec. to harden.                                                                                                  2.    Light guide
                                                                                      To overcome the drawbacks of Plasma Arc Curing Lights, they are used only                                                                                             process is continuously disturbed until the operator has finished the
The blue light is shown to the treatment area with the help of a rigid glass          for a maximum of 10 seconds. These units are also available with R Amps            3.    Button for activation / stopping polymerization                              contouring process16.
fibre bundle, flexible pipes or moulded polymer guides.                               Curing Modes to reduce polymerization shrinkage.                                   4.    Head piece with rechargeable lithium-ion battery                             The UV light cured composites have been
The halogen bulb has a life span on an average of 50 hours. The halogen lights        The Laser and plasma arc lights have been shown to produce highest heat            5.    Intensity indicator                                                          replaced by visible light activating systems with




                                                                                                        be




                                                                                                                                                                                                                                                                               be
requires maintenance as these bulbs degrade over time due to high                     which increases on the surface (up to 210C) and within the restoration up to                                                                                          a greatly improved ability to polymerize thicker
                                                                                                                                                                         6.    Main connection and charge control light
temperature leading to reduction in light output which results in reduced             140C. Compared to these halogen lights produce most temperature                                                                                                       increments up to 2mm16.
efficiency to cure dental composite, leading to restoration failure. Thus the         increase within the pulp chamber (increase of 2 0C) 24.                            7.    Intensity sensor
clinician gets a negative impression of the physical properties of composite                                                                                                                                                                                The visible light activating systems have been
                                                                                      LIGHT EMITTING DIODE (LED):                                                        8.    Battery charger
resins.                                                                                                                                                                                                                                                     initiated by halogen lights, whose light falls
                                                                                      LED’s are special diodes (Pic (6)), that emits light when connected in a           DISTINCTIVE FEATURES OF LED UNIT:                                                  within the absorption spectrum of the
Halogen lights have a fan to cool the unit which is noisy and produces some           circuit.                                                                           LED curing lights have many features, which benefit the operator and the           camphorquinone photo initiator (400nm-
vibration. It is important to remember that halogen curing lights must not be
                                                                                      A clear epoxy case enclosed the heart of an LED, the semi-conductor chip.          patient.                                                                           500nm) but however, halogen lights required
turned off until the fan has stopped running as it will overheat30. However,




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unless they are properly maintained and the output monitored they could be            Two wires extending below the LED epoxy enclosure indicate how the LED             LED curing units are available in both corded and cordless model. LED curing       maintenance as the bulbs degrade over time
a source of sensitivity due to the uncured resin.                                     should be connected into a circuit. The negative side of an LED lead is            units produce very less heat, therefore no fan is needed. No noise or vibration    due to high temperature leading to reduction in
                                                                                      indicated in two ways:                                                             and no need to wait until the fan shuts off before turning off the unit30and are   light output which results in reduction of
The halogen bulb, its reflection and the filter tend to degrade over time, due                                                                                                                                                                              effectiveness to cure dental composite, leading
to the production of light temperatures, which leads to the reduction in light        1) By the flat side of the bulb and 2) By the shorter of the two wires extending   easy to handle. Most of the LED unit is small compared to other curing units
                                                                                      from the LED, the negative lead should be connected to the negative terminal       and is available as convenient pen grip model.                                     to restoration failure. A constant check on the
output.
                                                                                      of a battery. LED’s operate at a relative low voltage (1 and 4 volts) and draw                                                                                        irradiance levels and timely replacement of bulb
A curing light meter can be used to observe the level of curing.                                                                                                         Schematic of LED 63 array:
                                                                                      currents between 10 and 40 milliamperes. Voltages and currents                                                                                                        and filter is therefore essential in these types of
LASER CURING UNIT:                                                                                                                                                       The normal LED is 5mm in diameter. In LED curing units, the LED is modified        units30.                                                      (Pic (8))
                                                                                      substantially above these values can melt a LED chip.
                                                                                                                                                                         to a layout of 3mm in diameter which is arranged in 3 circle rings25. The
Light Amplification by stimulated emission of radiation is excited in an              The most important part of a LED is the semi-conductor chip located in the         outer ring contains 36 LED arranged at an angle of 100, and the middle ring        The blue light emitting diodes (LED) used in
argon-filled chamber (Pic(4)), that produce a light which is focused and              center of the bulb. The chip has two regions separated by a junction. The ‘p’      contains 18 LED arranged at an angle of 200, and the inner most ring               dental curing lights last for thousands of hours in contrast to the 30 to 50
passed through the hand piece. With Argon laser, the wavelength is right for          region is dominated by positive electric charges and the ‘n’ region is             contains 9 LED arranged at an angle of 400. This arrangement helps the LED         hours life span of the light bulb used (in a conventional quartz tungsten
the curing of composite resin.                                                        dominated by negative electric charges. The junction acts as a barrier to the      unit to produce a narrow spectrum of light output.                                 halogen curing lights, they are rugged, do not require a filter, converts
                                                                                      flow of electrons between the p and the n regions. Only when sufficient                                                                                               electrical energy into light more efficiently and produce less heat.
                                                                                                                                                                         FIRST GENERATION LED UNIT:
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Laser curing is deeper and faster because of its higher intensity30.
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                                                                                                                                                                                                                     or
                                                                                      voltage is applied to the semi-conductor chip, can the current flow and the                                                                                           Consequently, LED lights may soon replace incandescent light sources33.
Laser curing is monochromatic and has a wavelength of 470 nm.      34
                                                                                      electrons cross the junction into the p region.                                    The first generation of LED curing lights, which often contain multiple LEDs,
                                                                                                                                                                         had a relatively low power output33 and they did not perform well as               To achieve adequate polymerization some dental resins require the lower
The advantages of laser curing over halogen lights are that polymerization is         When sufficient voltage is applied to the chip across the leads of the LED,                                                                                           wavelengths delivered by third generation LED curing lights31. Third
                                                                                                                                                                         compared to conventional halogen light curing units especially when used to
                                                                                      electrons can move easily in only one direction across the junction between
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uniform, increased depth of curing, shorter curing time, etc., however its                                                                                               polymerize resins containing certain co-initiators in addition to                  generation LED lights use a combination of LEDs to produce a broader
drawbacks are that the rise in temperature can be detrimental to pulp,                the p and n regions. In the p region there are many more positive than                                                                                                spectral output and these lights may polymerize a broader range of resins
                                                                                                                                                                         camphorquinone.
adjacent restorations are also affected and high cost of the equipment.               negative charges.                                                                                                                                                     than the second generation curing lights31 33.
                                                                                                                                                                         SECOND GENERATION LED UNIT:
PLASMA ARC CURING UNIT:                                                               In the n region the electrons are more numerous than the positive electric                                                                                            he LED curing lights do have their disadvantages such as a narrow spectrum




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                                                                                      charges. When a voltage is applied and the current starts to flow, electrons       A second generation LED curing unit uses only single or two high power LED
Plasma Arc Curing Light (Pic(5)), contain two tungsten electrodes separated                                                                                                                                                                                 of cure, only suitable for composites based on camphoroquinone photo
                                                                                      in the n region have sufficient energy to move across the junction into the p      s which delivers a different spectral distribution with a greater power output
by a small gap , between which a high voltage is generated. The resulting                                                                                                than the first generation light and may therefore offer better performance         initiator and less effective for polymerizing darker shades of many micro filled
                                                                                      region. Once in the p region the electrons are immediately attracted to the
spark ionizes the xenon gas, that is present in the environment, so as to                                                                                                and shorter curing times26. LED curing light adequately polymerized the            composites.34 Different shades of the same brand of composite can behave
                                                                                      positive charges due to the mutual coulomb forces of attraction between
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produce a conductive gas know as ‘plasma’.                                                                                                                               hybrid resin composite in a timely manner, but not the micro fill resin            differently when irradiated by a broad spectrum versus narrow spectrum LED
                                                                                      opposite electric charges. When an electron moves sufficiently close to a
The unit has a liquid-filled light guide which filters the harmful wavelength         positive charge in the p region, the two charges recombine. Each time an           composite.                                                                         light33.
and transmits light of appropriate wavelength to the tip. The unit produces           electron recombines with a positive charge, electric potential energy is           THIRD GENERATION LED UNIT:                                                         TTO be prudent, the clinician should always place their curing lights at
high a intensity light (over 2,000 mco/cm2) and can polymerize composites             converted into electromagnetic energy. For each recombination of a                                                                                                    clinically relevant distance so as to deliver sufficient total energy, and the
rapidly in 6-10 seconds34.                                                            negative and a positive charge, a quantum of electromagnetic energy is             The third generation LED lights (pic (8)) use a combination of LEDs to produce
                                                                                                                                                                                                                                                            recommended irradiation time that will polymerize both the brand and shade
                                                                                      emitted in the form of a photon of light with a frequency characteristic of the    a broader spectral output31 and these lights may polymerize a broader range
                                                                                                                                                                                                                                                            of resin composite they are using. 6, 8, 9 ,15
                                                                                      semi-conductor material. The most commonly used semi-conductor                     of resins than the second generation curing lights 32.
                                                                                                                                                                                                                                                            REFERENCES:
                                                                                      material in LED unit is gallium nitrate, which produce a more narrow spectral      Third generation LED curing lights contains 5 LEDs33. The central LED delivers
                                                                                      range that is closer to the absorption spectrum of the camphorquinone (450         the narrow, high-power spectral bandwidth that is found in a second                1.    Ruyter IE, Oysaed H. Conversion in different depths of ultraviolent and
                                                                                      to 490 mm) that initiates resin polymerization. LED has a long life of 1, 00,000   generation light. The 4 peripheral low-power LEDs are angled towards the                 visible light activated composite materials. Acta Odontol Scand 1982;
                                                                                      hours.                                                                             center so that they illuminate both the center and the periphery of the                  40(3):179-92.
                                                                                                                                                                         composite resins. The increased micro hardness from the third generation           2.    Yearn JA. Factors affecting cure of visible light activated composites.
                                                                                                                                                                         mode occurred both at center and towards the edges of the composite resin.               Int Dent J 1985; 35(3); 218-25.
                                                                                                                                                                         This indicates that at a 2mm distance, the 4 lower wavelength LEDs, located
                                                                                                                                                                         at each of the 4 corners of the head of the light, provided relatively even        3.    Eliades GC, Vougiouklakis GJ et al. Degree of double bond conversion in
                                                                                                                                                                         coverage of curing composite resins with the lower wavelengths33.                        light-cured composites. Dent mater 1987; 3(1):19-25.
                                                                                                                                                                         The broader spectrum third generation LED light produced composites that
                                                                                                                                                                         were harder and also polymerizes a wider range of composites than narrow                               Nothing is so strong as gentleness, and
                                                                                                                                                                         spectrum second generation lights32.                                                                    nothing is so gentle as true strength.
                   (Pic (4))                           (Pic (5))                                         (Pic (6))                        (Pic (7))
                                                                                                                                                                                                                                                                                          Ralph Sockman



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4.   McCabe JF, Carrick TE, Output from visible-light activation units            20. Harris JS, Jacobsen PH et al, The effect of curing light intensity and test
     and depth of cure of light-activated composites. J. Dent Res
     1989; 68(11): 534-9.
                                                                                      temperature on the dynamic mechanical properties of 2 polymer
                                                                                      composites. J Oral Rehabil 1999; 26(8):635-9.
                                                                                                                                                                           ENIGMA OF DISTALIZATION - A
5.   Caughman WF, Correlation of cytotoxicity, filler loading and curing time
     of dental composites. Biomaterials 1991; 12(8):737-40.
                                                                                  21. Davidson CL, de Gee AJ. Light curing units, polymerization and clinical
                                                                                      implications. J Adhens Dent 2000; 2(3):167-73.                                       COMPARATIVE CASE REPORT
6.   Rueggeberg FA, Caughman WF et al. Factors affecting cure at depths           22. Correr Sobrinho L, De Goes MF et al. Correlation between light intensity
     within light-activated resin composites. Am J Dent 1993; 6(2):91-5.              and exposure time on the hardness of composite resin. J Mater Sci




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                                                                                                                                                                                                                                                                                be
7.   Lee SY Greener EH. Effect of excitation energy on dentin bond strength           Mater Med 2000; 11:361-4.                                                                                                                                                                                         Dr. K.Rajesh Reddy,
     and composite properties. J. Dent 1994; 22(3):175-81.                        23. Tanoue N, Koishi Y et al, Curing depth of different shades of a photo-                                                                                                                                              Dr.G.Vijay Reddy,
8.   Nomoto R, Uchida K et al, Effect of light intensity on polymerization of
                                                                                      activated prosthetic composite material. J Oral Rehabil 2001;                                                                                                                                                        Dr. A.Rakesh Rao
                                                                                      28(7):618-23.
     light-cured composite resins. Dent Mater J 1994; 13(2):198-205.
                                                                                  24. St-George AJ, Curing light intensity effects on wear resistance of 2
9.   Rueggeberg FA, Caughman WF et al. Effect of light intensity and
                                                                                      resin composites, Oper Dent 2002; 27(4):410-7.                                                                                                                       Fabrication: The pendulum springs consist of:
     exposure duration on cure of resin composite. Oper Dent 1994;                                                                                                  INTRODUCTION
     19(1):26-32.                                                                 25. Alexander Uhl, Robin W et al, Optical power outputs, spectra and                                                                                                     1.    Recurved molar insertion wire
                                                                                      dental composite depths of cure obtained with LED units. J Dent
                                                                                                                                                                    The controversy of extraction & non extraction is not new, the battle




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10. Curtis JW, Jr., Rueggeberg FA et al, Curing efficiency of the Turbo Tip.                                                                                        was going on since the time of E.H.Angle. How Dr. Charles tweed got                    2.    Horizontal adjustment loop
                                                                                      mater. 2002; Vol: 193. No.8.
    Gen Dent 1995; 43(5):428-33.                                                                                                                                    the worst tongue lashing and not a word of applause, when he
                                                                                  26. Richard B.T Price, Evaluation of a second generation LED curing lights. J                                                                                            3.    Closed helix
11. Shortall AC, Wilson HJ et al. Depth of cure of radiation activated                                                                                              presented cases, which were treated by extraction is well known.1
                                                                                      Can Dent Assoc 2003; 69(10):666.                                                                                                                                     4.    Loop for retention in acrylic button
    composite restoratives influence of shade and opacity. J Oral Rehabil                                                                                           Interest in nonextraction therapy has accelerated the use and
    1995; 22(5):337-42.                                                           27. Franz A, Konig F et al, Cytotoxic effects of packable and nonpackable         development of several other techniques - expansion, proximal slicing,                 The springs are placed close to center of Nance button while the Nance
                                                                                      dental composites Dent mater 2003;19(5):382-92.                               uprigthing and last but not the least is molar distalization, which                    button is kept 5mm apart from teeth. The anterior portion aids in retention
12. Shortall AC, Light curing unit effectiveness assessed by dental
    radiometers. J Dent 1995; 23(4):227-32.                                       28. Caldas DB, Almedida J, Influence of curing tip distance on resin              requires minimal patient compliance. Various distalizing appliances                    with bands on upper 1st premolars and solder retaining wire to the bands.
                                                                                      composite knoop hardness number, using three different curing units.          evolved with their respective pros and cons, namely, extra-oral                        CASE REPORT:
13. Nomoto R, Effect of light wavelength on polymerization of light cured             Oper Dent 2003; 28(3)315-20.
    resins, Dent mater J. 1997; 16: 60-73.                                                                                                                          traction2-4, removable appliances with finger spring5, Wilson’s
                                                                                                                                                                                                                                                           A 12 yrs old female patient was diagnosed as skeletal class 1 with Angle’s
                                                                                  29. Uho A et al, Second generation LEDs for the polymerization of oral            arches6-7, sliding jigs with class II inter maxillary elastics8-10,                    class II div 1 with end on molar relation bilaterally, mild deep bite and pleasing
14. Ferracane JL, Wear and marginal breakdown of composites with                      biomaterials. Dent mater ; 2004: 20:80-87.                                    ACCO11, pendulum12, K-loop13 and mini-implants.14
    various degrees of cure. J Dent Res 1997; 76(8)1508-16.                                                                                                                                                                                                profile. Second molars were not yet erupted. The extraction mode of
                                                                                  30. Victoria L Wallace, Terminology, technology and troubleshooting:              INDICATIONS                                                                            treatment was ruled out as nose tip was pointed up and there was only mild
15. Nomoto R. Effect of light wavelength on polymerization of light cured
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                                                                                                                                                                                                                   or
                                                                                      curing lights. Dental assistant 2005; pg 1-4.                                 1. In a growing child -To relieve mild crowding & causes permanent                     space discrepancy. Hence, it was planned for non-extraction with bilateral
    resins, Dent mater J 1997; 16(1):60-73.
                                                                                  31. Price RB, Felix CA, Evaluation of a dual peak third generation LED curing           increase in arch length of about 2mm on each side.                               molar distalization by pendulum appliance. Head gear distalization also could
16. Kenmeth J Anusaive , Restorative resins. Philips science of dental                light. Compend Contin Educ Dent. 2005; 26: 331-338.                           2. Late mixed dentition - When lower E space – utilized for relief of                  have been done, but patient was not ready to wear it. We choose pendulum
    materials 1998; P: 273-301.                                                                                                                                           anterior crowding.                                                               appliance as it was patient compliant and only one activation period was
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                                                                                  32. Hicks RA, Burgess JO. Hardness of Eight composites Cured with two
17. Martin FE, E Survey of the efficiency of visible light curing units. J Dent       LED curing Lights, J Dent Res. 2005; 84.                                      3. Non-growing patient - To regain lost arch length and blocked out                    needed for the process to be successful. These are the two main advantages
    1998; 26(3):239-43.                                                                                                                                                   canines.                                                                         of the appliance when compared with other appliances requiring patient
                                                                                  33. Richard BT Price, Corey A Felix, Third generation vs. a second                                                                                                       compliance such as headgear and Class II elastics.
18. Rueggeberg F, Contemporary issues in photocuring. Compend contain                 generation LED curing light: Effect on knoop Micro hardness. J                4. Upper second molar extraction.
    educ Dent Suppl 1999;25 :S4-15.




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                                                                                      Compendium 2006; 27(9)490-497.                                                5. End on molar relationship with mild to moderate space requirement.                  K-LOOP MOLAR DISTALIZING APPLIANCE: (Fig 2)
19. Pilo R, Oelgiesser D et al, A survey of output intensity and potential for    34. Ramya raghu . Clinical Operative Dentistry Emmesis Med.Pub.2008.              6. Cases with less than a full cusp class II molar relationship.                       K-loop was given by Varun Kalra, made up of 0.017 x 0.025 TMA with each
    depth of cure among light curing units in clinical use. J Dent 1999;              pg328-329.                                                                                                                                                           loop being 8mm long and 1.5mm wide. Each leg is bent at 20° which are
    27(3):235-41.                                                                                                                                                   CASE SELECTION
                                                                                                                                                                                                                                                           inserted in to the molar tubes and premolar bracket. Stops are bent into the
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                                                                                                                                                                    1. Normal or near normal mandibular arch.
                                                                                                                                                                                                                                                           wire 1mm distal to the distal mark and 1mm mesial to the mesial mark. Each
                                                                                                                                                                    2. Late mixed dentition is ideal, but at early permanent dentition also it             stop should be well defined and about l.5mm long. These bends help keep
                                                                                                                                                                          can be done if growth is still left in maxillary tuberosity area. 16-17 yrs-     the appliance away from the mucobuccal fold, allowing a 2mm activation of
                                                                                                                                                                          males, 14-15 yrs-females.                                                        the K-loop. The 20° bends in the appliance legs produce moments that
                                                                                                                                                                    3. Molars placed normally - buccolingually.                                            counteract the tipping moments created by the force of the appliance, and
                                                                                                                                                                    4. 3rd molars – absent.                                                                these moments are reinforced by the moment of activation as the loop is
                                                                                                                                                                    5. Profile considerations - well developed nose & chin                                 squeezed into place. Hence, the molar undergoes translatory movement
                                                                                                                                                                    6. High MPA – contraindicated - wedging effect                                         instead of tipping.13 It was reactivated after 6-8weeks.
                                                                                                                                                                    7. Space discrepancy - not very severe.                                                CASE REPORT:
                                                                                                                                                                    This article presents an illustration of three different modes of distalization with   A 14 yrs old female patient was diagnosed as skeletal class I, Angle’s class II
                                                                                                                                                                    - pendulum appliance, K-loop, mini-implants and their comparison.                      div 1 with spacing both the molars in end on relation, pleasing profile, normal
                                                                                                                                                                    PENDULUM APPLIANCE: (Fig 1)                                                            overjet and overbite. It was planned for non-extraction with K-loop
                                                                                                                                                                                                                                                           distalization. The nance button was soldered to upper first premolar bands
                                                                                                                                                                    Pendulum, was introduced by Hilgers in 1992 which consists of a palatal nance
                                                                                                                                                                                                                                                           for anchorage and the rest of dentition was bonded. K-loop was activated by
                                                                                                                                                                    component with rests that are bonded to the occlusal surface of the first
                                                                                                                                                                    and/or second premolar teeth. The distalizing mechanism consists of bilateral          giving alpha and beta bends and engaged in the auxillary tube on molars. The
                                                                                                                                                                    helical springs of 0.032 Titanium Molybdenum Alloy (TMA). The springs of the           advantages of it were: simple and yet efficient, controls the moment to force
                                                                                                                                                                    appliance produce 200 to 250 g of force in a swinging arc movement, from the           ratio, easy to fabricate and place, hygiene, minimal patient co-operation and
                                                                                                                                                                    midline of the palate to the upper molars, hence the name pendulum.12                  low cost.



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MINI IMPLANT DISTALIZATION: (Fig 3)                                                 4.    Graber TM. Appliances at the crossroads. Am J Orthod 1956;42:683                             Figure 1: pendulum distalization
The intraoral molar distalization appliances such as the pendulum and K- loop             701.
effectively distalize the maxillary molar teeth to a Class I relationship without   5.    Cetlin NM, Ten Hoeve A. Nonextraction treatment. J Clin Orthod
any cooperation on the part of the patients. Nevertheless, anchorage loss                 1983;17:396-413.
occurs with the use of these appliances, with a significant maxillary incisor       6.    Wilson RC, Wilson WL. Enhanced orthodontics: book 1, concept,
proclination and an increase in overjet at the end of the distalization.14                treatment and case histories. Denver, Colorado: Rocky Mountain
A 14 yrs old female was diagnosed as skeletal class I with Angle’s class II               Orthodontics, 1988.




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                                                                                                                                                                                                                          be
division 1 with bilaterally end on molar relation, imbrications, pleasing profile   7.    Wilson RC, Wilson WL. Enhanced orthodontics: book 2, force
and 4mm overjet. The anchorage requirement was critical; hence it was                     systems mechanotherapy manual. Denver, Colorado: Rocky
planned for distalization with mini implants. Two mini implants (orlus) of                Mountain Orthodontics, 1988.
7mm were placed on palatal surface between second premolar and first
molar. A palatal arch was fabricated with two hooks soldered at the canine          8.    Tweed CH. Clinical orthodontics. Vol. 1. St Louis: CV Mosby, 1966.
area. The hooks were positioned, so that the line of action of force would          9.    Gianelly AA, Vaitas AS, Thomas WM, Berger OG. Distalization of
pass through the centre of resistance of molar. Thus, bodily distalizing                  molars with repelling magnets. J Clin Orthod 1988;22:40-4.              Post distalization                                       Predistalization
movement of molar could be achieved.                                                10.   Gianelly AA, Vaitas AS, Thomas WM. The use of magnets to move




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DISCUSSION                                                                                molars distally Am J Orthod Dentofac Orthop 1989;96:161-7.                                   Figure 1: pendulum distalization

This article compares three different methods of distalization, namely              11.   Bernstein L. The ACCO Appliance. J Clinal Orthod 1969;3:461-468.
pendulum appliance, K- loop appliance and mini implant distalization. Intra         12.   Joseph A A,Butchart CJ.An evaluation of the pendulum distalizing
oral devices have advantages of patient compliance, but with greater                      appliance. Seminars in orthodontics 2000;6:129-135
anchorage loss. Extra oral devices overcome the problem of anchorage, but
                                                                                    13.   K loop distalizer. Kalra.V J Clinic Orthod 1995, 298-301
are not patient compliant. The consolidation of overjet by fixed appliance,
following protrusion of incisors with molar distalization causes round tripping     14.   Lee JS, Kim JK, Park Y, Vanarsdall RL. Applications of orthodontic
of the incisors, which may in turn increase the risk of complications.                    mini-implants. Quintessence Publishing Co., 2007.
The literature regarding the effect of distalization appliance mostly focuses       3.    Bernardi F. A cephalometric analysis of the stability and type of
on dental movements. In recent years, the trend of orthodontics has been to               movement obtained in Class II, division 1 malocclusions treated with
treat faces; therefore to define the effect of these appliances from point of             extra-oral forces. [Masters thesis.] St Louis: Saint Louis University
profile change has become important. The data following the removal of                    Department of Orthodontics, 1956.
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distalization appliance (pendulum and K loop) showed that the anchorage             4.    Graber TM. Appliances at the crossroads. Am J Orthod 1956;42:683
loss was evident as illustrated (Fig 4). Even, the upper lip protrusion was               701.                                                                    Post distalization                                       Predistalization
more with the K loop and minimal patient comfort with K loop in the sulcus.         5.    Cetlin NM, Ten Hoeve A. Nonextraction treatment. J Clin Orthod
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On evaluating pendulum appliance, distalization has been achieved with                    1983;17:396-413.                                                                             Figure 1: pendulum distalization
comparatively less anchor loss than K-loop but the molar being tipped
distally than bodily movement.                                                      6.    Wilson RC, Wilson WL. Enhanced orthodontics: book 1, concept,
                                                                                          treatment and case histories. Denver, Colorado: Rocky Mountain
The above said disadvantages are well addressed with mini implant                         Orthodontics, 1988.




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distalization as illustrated with efficient biomechanical principles (Fig 5). The
molar was distalized bodily with hardly any anchor loss.The added                   7.    Wilson RC, Wilson WL. Enhanced orthodontics: book 2, force
advantage with the palatal arch and palatal implants design used was that                 systems mechanotherapy manual. Denver, Colorado: Rocky
                                                                                          Mountain Orthodontics, 1988.
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bonding of the rest of the dentition is not required and the second premolar
drifts distally into the space created by driftodontics. This minimizes the         8.    Tweed CH. Clinical orthodontics. Vol. 1. St Louis: CV Mosby, 1966.
duration of treatment and thereby relives the anterior crowding. Even from          9.    Gianelly AA, Vaitas AS, Thomas WM, Berger OG. Distalization of
patient’s point of view, mini implants were more acceptable as they were                  molars with repelling magnets. J Clin Orthod 1988;22:40-4.
less bulky, ease of hygiene maintenance and relatively less treatment
duration.                                                                           10.   Gianelly AA, Vaitas AS, Thomas WM. The use of magnets to move
                                                                                          molars distally Am J Orthod Dentofac Orthop 1989;96:161-7.
References                                                                                                                                                        Post distalization                                       Predistalization
                                                                                    11.   Bernstein L. The ACCO Appliance. J Clinal Orthod 1969;3:461-468.
1.     Strang RH: Highlights in 64 years in Orthodontics.Angle Orthod
                                                                                    12.   Joseph A A,Butchart CJ.An evaluation of the pendulum distalizing            Figure 4                                                  Figure 5
       44,1974
                                                                                          appliance. Seminars in orthodontics 2000;6:129-135
2.     Graber TM. Extraoral force-facts and fallacies. Am J Orthod
       1955;41:490-505.                                                             13.   K loop distalizer. Kalra.V J Clinic Orthod 1995, 298-301

3.     Bernardi F. A cephalometric analysis of the stability and type of            14.   Lee JS, Kim JK, Park Y, Vanarsdall RL. Applications of orthodontic
       movement obtained in Class II, division 1 malocclusions treated with               mini-implants. Quintessence Publishing Co., 2007.
       extra-oral forces. [Masters thesis.] St Louis: Saint Louis University
       Department of Orthodontics, 1956.




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                                                                                                                                                                       EXCLUSION CRITERIA:                                                            Statistics

      EVALUATION OF L-FUCOSE LEVELS IN                                                                                                                                 Subjects with other systemic diseases / conditions.Subjects who are on anti
                                                                                                                                                                       inflammatory and anti microbial drugs for 2 months or more.Subjects who         N
                                                                                                                                                                                                                                                                                                      Normal
                                                                                                                                                                                                                                                                                                         15
                                                                                                                                                                                                                                                                                                                       Diabetes
                                                                                                                                                                                                                                                                                                                          15

      SERUM OF HEALTHY AND CHRONIC
                                                                                                                                                                       smoke cigarrates or chew tobacco.                                               Valid                                             0                0
                                                                                                                                                                       METHOD OF COLLECTION OF SAMPLE:                                                                                                14.1340          16.0913
                                                                                                                                                                                                                                                       Missing
      PERIODONTITIS PATIENT WITH AND
                                                                                                                                                                       COLLECTION OF SERUM:
                                                                                                                                                                                                                                                       Mean                                           1.40496          1.93881




                                                                                                       be




                                                                                                                                                                                                                                                                          be
                                                                                                                                                                       5 ml. of venous blood sample was drawn from the subject through
                                                                                                                                                                       disposable syringes and was transferred to centrifuge tube. Blood sample        Std. Deviation
                                          Dr. Rahul Bhandary, Reader, Dept of
      WITHOUT DIABETES -             Periodontics A.b.shetty Memorial Institute
                                                of Dental Sciences Deralakatte
                                                                                                                                                                       was allowed to stay in centrifuge tube undisturbed for 30 minutes. Then it
                                                                                                                                                                       was centrifuged and serum was separated and sent immediately for
                                                                                                                                                                                                                                                      Statistics
                                                                                                                                                                       biochemical analysis.
      A BIOCHEMICAL STUDY     Dr. Prasad B. Shetty, Assistant Professor Dept of
                                     Periodontics A.b.shetty Memorial Institute                                                                                        BIOCHEMICAL ANALYSIS:
                                                                                                                                                                                                                                                       N
                                                                                                                                                                                                                                                                                                      Normal
                                                                                                                                                                                                                                                                                                         15
                                                                                                                                                                                                                                                                                                                      Non diabetes
                                                                                                                                                                                                                                                                                                                           15
                                                                                                  of Dental Sciences Deralakatte                                       L-Fucose was estimated by WINZLER METHOD using spectrophotometer
                                                                                                                                                                                                                                                       Valid                                             0                 0
                                                                   Prof. (Dr.) Sucheta Kumari, Dept of Bio Chemistry A.b.shetty                                        was carried out at central research labortory, ABSMIDS, Deralakatte




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                                                                               Memorial Institute of Dental Sciences Deralakatte                                                                                                                                                                      14.1340           17.5673
                                                                                                                                                                       ESTIMATION OF L- FUCOSE LEVELS:                                                 Missing
                                                   Mr. Praveen Kumar, Post Graduate Dept of Bio Chemistry Mangalore University
                                                                                                                                                                       0.1 ml of sample + 5 ml 95% ethyl alcohol. Mixture centrifuged at 1500 rpm      Mean                                           1.40496           1.00804
                                                                                                                                                                       for 15 minutes. Precipitate was suspended in 5 ml 95% ethyl alcohol.            Std. Deviation
                                                                                                                                                                       Recentrifuged for 15 minutes. Resultant precipitate was dissolved in 1 ml of
                                                                                                                                                                       0.1 ml NaOH. The “reagent blank” and “standard” tubes prepared adding 1
ABSTRACT:                                                                            Fucose has been found to be present in endothelial cells and cells of erythroid
                                                                                                                                                                       ml water and 1ml working standard. To these 4.5 ml ice- cold sulphuric acid-   Correlations
Recent advances in the etiopathogenesis of periodontal disease have                  series. Whenever there is inflammation with respect to gingiva and                water mixture. This mixture then transferred to boiling water bath for 3
revealed that it is due to complex interaction between plaque microbiota and         periodontium, cell lysis takes place due to host microbial interaction leading    minutes.                                                                                                                       Normal            Diabetes
host-immune system. However various systemic conditions which influence              to increased release of fucose from cells. Recent studies indicate that                                                                                           Normal                  Pearson                  1                 .149
                                                                                     coaggregation of Fusobacterium nucleatum and Porphyromonas gingivalis             Then cooled in tap water 0.1 ml of cysteine reagent added to “reagent
the immune response play a role in etiopathogenesis of periodontal disease.                                                                                                                                                                            Correlation                                                        .597
                                                                                     was inhibited by D-Fucose but not by L-Fucose. So if L-Fucose is being used,      blank”, “standard” and “test” 0.1 ml of water added to “serum-blank”. After
One such condition is diabetes.                                                                                                                                        60 minutes mixture transferred to cuvettes and absorbance read at 400 nm                                Sig. (2-tailed)          15                 15
                                                                                     coaggregation will proceed without hindrance leading to increase in                                                                                               N                                               .149                 1
L-fucose is a monosaccharide, which is usually a terminal sugar in most                                                                                                and 430 nm in spectrophotometer.
                                                                                     infection.This will result in increase in inflammation and hence due to host-
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                                                                                                                                                                                                                                       &
                                                                                                                                                                                                                                                       Diabetes                Pearson
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                                                                                                                                                                                                                 or
plasma glycoprotein and blood group substance as well as in tissue                   microbe interaction there will be lysis of cells of erythroid series and          STATISTICAL ANALYSIS:
glycoproteins. Elevated serum levels of protein bound fucos have been                                                                                                                                                                                  Correlation                                                       .597
                                                                                     endothelial cells leading to increased levels of L-Fucose.                        The results obtained were tabulated and subjected to statistical analysis
reported in patients.                                                                                                                                                                                                                                                          Sig. (2-tailed)          15                15
                                                                                     OBJECTIVES OF THE STUDY:                                                          using Student t test and ANOVA test.
Materials and methods: patients reporting to the department of periodontics                                                                                                                                                                            N
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i.e., 15 healthy subjects (control group) and 15 diabetic subjects with              To assess the
                                                                                     ? levels of L-Fucose in serum of healthy subjects.
periodontitis case (study group).                                                    To assess
                                                                                     ? the levels of L-Fucose in serum of subjects with chronic                             Group                                            L-Fucose level
                                                                                                                                                                                                                                                      Correlations
L-fucose is estimated according to the method of Winzler.                                periodontitis & with diabetes.
                                                                                                                                                                                                                                                                                                      Normal          Non diabetes




                                                                                                                                                                                            r
Results: One way ANOVA was applied. It was found that there was                      MATERIALS AND METHODS:                                                                 Normal                                           14.13 + 1.405
                                                                                                                                                                                                                                                       Normal                  Pearson                  1                .130
statistically significant difference between three groups in the l fucose level      SOURCE OF DATA:
                                                                                                                                                                                                                                                       Correlation                                                       .645
INRODUCTION:                                                                         60 subjects reporting to the Department of Periodontics of A.B.SHETTY                  Periodontitis with Diabetes                      16.09 + 1.939                                     Sig. (2-tailed)          15                 15
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Fucose is a deoxyhexose that is present in a wide variety of organisms. L-           MEMORIAL INSTITUTE OF DENTAL SCIENCES, wereselected.                                                                                                              N                                               .130                1
Fucose(6 deoxy-L-galactose) is a monosaccharide that is a common                     METHOD OF COLLECTION OF DATA:                                                          Periodontitis without Diabetes                   17.57 + 1.008             Non diabetes            Pearson
component of many N- and O- linked glycans and glycolipids produced by               Subjects aged between 20-55 years were included in the study.                                                                                                     Correlation                                                       .645
mammalian cells. It is found in endothelial cells, platelets, cells of erythroid                                                                                                                                                                                               Sig. (2-tailed)          15                15
series, cells of salivary glands, gastric cellsand cells of intestinal epithelium.   GROUP A: 15 subjects with healthy gingiva
                                                                                                                                                                                                                                                       N
In mammals, fucose containing glycans have important roles in blood                  GROUP B: 15 subjects with chronic periodontitis & with diabetes.
transfusion reactions, selectin mediated leucocyte endothelial adhesion and          GROUP C: 15 subjects with chronic periodontitis & without diabetes.
host microbe inter-actions.The ABO blood group antigens are among the                SCREENING EXAMINATION INCLUDES:                                                                                                                                  Paired Samples Correlations
most well known fucosylated glycans. A,B and H antigens are highly                                                                                                                                                                                                                               N      Correlation         Sig.
                                                                                     Medical history and Dental history of the subjects were taken.
immunogenic and high titres of complement fixing IgM antibodies against
                                                                                     Gingival index was taken according to criteria given by Loe and Silness.                                                                                          Pair 1        Normal & diabetes           N            .149         .597
the molecules prevent successful red blood cell transfusion to incompatible
individuals.                                                                         Probing depth was determined.
The gastric pathogen Helicobacter pylori is capable of attachment to the             CRITERIA FOR SELECTION:                                                                                                                                          Paired Samples Correlations
gastric epithelium via host expression of LEWISb antigen. LEWISb antigen is          INCLUSION CRITERIA:                                                                                                                                                                                         N      Correlation         Sig.
synthesised by fucosyl transferases. It may induce autoimmune mediated
                                                                                     Subjects diagnosed with type II diabetes were included. Subjects who have                                                                                         Pair 1          Normal & Non              15           .130         .645
damage to gastric epithelium leading to chronic atrophic gastritis.
                                                                                     a pocket of probing depth of equal to or >5mm or evidence of radiographic                               With diabetes                                             diabetes
Fucose is an essential component of carbohydrate ligand for the selectin                                                                                                                 Normal
                                                                                     bone loss in atleast 30% sites were included.                                                                   Without diabetes
family of cell adhesion receptors. Interaction between selectins and their
ligands enable the rolling of leucocytes on the endothelium.


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DISSCUSSION                                                                       LIST OF REFERENCES:
According to Arthur (5) and others the increased fucose: protein ratio can be     1.   P.K.SHETTY and T.N.PATTABIRAMAN.2004. SALIVARY GLYCOPROTEIN
used as an indicator for periodontotal disease progression. Dharapur (11)              AS INDICATORS OF ORAL DISEASES.19,1:97-101.




                                                                                                                                                            Events
reported an increase in fucose and protein levels in diabetes in saliva. The      2.   P.E.KOLENBRANDER and R.N.ANDERSEN.1989. INHIBITION of
alteration in basement membrane permeability as proposed by Mandel (16)                COAGGREGATIONBETWEEN FUSOBACTERIUM nucleatum and
is one of the causes for increased protein and fucose values in saliva in              PORPHYROMONAS gingivalis by LACTOSE and RELATED
diabetes. The present study show that fucose level in saliva is increased both         SUGARS.INFECTION AND IMMUNITY. 57,10:3204-3209




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                                                                                                                                                                                be
in periodontitis and gingivitis. However when normalised to protein               3.   DR.M.D.FABBRO, L.FRANCETTI G.BULFAMANTE, M.CRIBIU
concentration, fucose values did not differ in gingivitis and periodontitis            G.MISEROCCHI and R.L.WEINSTEIN.2001.FLUID DYNAMICS of
compared tonormal subjects unlike in diabetes. It is probable the increased            GINGIVAL TISSUES in TRANSITION FROM PHYSIOLOGICAL
glycoprotein level is offset by increased fucosidase activity leading to               C O N D I T I O N t o I N F L A M M AT I O N . J O U R N A L O F
comparable level of fucose per unit of protein in gingivitis and periodontitis.        PERIODONTOLOGY.72,1:65-73
The glycosidases could be of bacterial origin since adhesion of materials         4.   N.YAMOGUCHI, M.KAWASAKI,Y.YAMASHITA, K.NAKASHIMA and
containing microorganisms at the tooth surfaces is considered to be a                  T.KOGA.1995. ROLE of the CAPSULAR POLYSACCHARIDE-LIKE




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primary factor in the development of periodon l diseases (17-22).                      SEROTYPE SPECIFIC ANTIGEN in RESISTANCE of ACTINOBAC ILLUS
The microorganisms either can release hydrolytic enzymes or agents that                actinomycetemcomitans to PHAGOCYTOSIS by HUMAN
may cause direct damage to periodontal tissue by stimulating host mediated             POLYMORPHONUCLEAR LEUKOCYTES. INFECTION AND
responses.                                                                             IMMUNITY.63,12:4589-4594.
                                                                                  5.   D.J.BECKER and J.B.LOWE.2003.FUCOSE:biosynthesis and biological
                                                                                       function in mammals. GLYCOBIOLOGY.13:41R-51R.
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