Vol. 30 No. 02 Apr-Jun 2021

Humayun Kaleem Siddiqui          BDS, FCPS

Sharjeel Bashir                              BDS

INTRODUCTION

Temporomandibular joint (TMJ) dislocation indicates a non-self-limiting displacement of the mandibular condyle, outward from it functional position within the glenoid fossa and posterior slop of the articular eminence.
It’s an acute phenomenon which can transform into chronic condition after multiple recurrence episodes.1 Oral surgeon is frequently called for the management of recurrent TMJ dislocation in adults. In pediatric population,TMJ dislocation sometimes caused by trauma related to wide opening of the mouth during vomiting, yawning and dental procedures considerably under general anesthesia.1,2 Recurrent TMJ dislocationsin adults have been reported and are common findings in practice. We are presenting our case as in children this is extremely rare except for few reported cases. Management of TMJ dislocation in adults are well described; in acute condition, manual technique use for reduction.1,3 In recurrent TMJ dislocations, surgery is recommended commonlyeminectomy described by Myraugh in 1951 is used for correction. Other procedures include capsule tightening, Dautery procedure, intra articular injections and many others.4 In pediatric patients these surgical procedures are not warranted generally owing to
small structures and risk of facial nerve injury. We are presenting a case reported with recurrent TMJ dislocation in a 3-year-old child and discuss its management with available options.

CASE REPORT

A 3-year-old baby girl came to emergency department of tertiary care hospital with a complaint of open mouthfor the last 6 hours. According to her mother, she had stopped eating suddenly for many hours that morning and throws all food out when someone tries to feed her. Oninitial examination, the patient looked distressed and unable to close mouth on repeated requests.At the Emergency Room (ER), doctor ENT on call was called immediately for opinion. After initial examination, CT-Scan was ordered to facilitate further diagnosis.CT-Scanreport showedan asymmetric soft

Figure 1: Clinical picture shows open mouth with jaw dislocation

Figure 2: Radiographic picture showing slide of sagittal plane of CT-Scan with dislodgment of head of condyle of mandible from glenoid fossa-base of skull.

tissue density mass in the retropharyngeal area at the level of C1 and C2, showing more bulk on right side. Some subtle radiolucencies are also identified within it.Possibility of a lowdensity foreign body or retropharyngeal abscess cannot be entirely excluded.A quick examination under anesthesia (EUA)was planned and performed to relieve the patient from the abcess/growth. During EUA of the patient, no subsequent finding of any growth or collection or pus was observed.Following recovery, patient still had the same problem of recurrent open mouth which caused distress and raised concern for the family due to lack of eating. The patient was then admitted to pediatric ward for medical assistancesince she was unable to eat for many hours and was dehydrated. On a much detailed history, parents revealedthat baby girl along with her mother were visiting Pakistan on vacations and the very first episode of open jaw occurred after one week of arrival and was resolved itself which lasted 2-3 hours. A month later, a more pronounced episode occurred which did not resolve itself and they had to report to ER.
The patient was sent to oral and maxillofacial surgeon, on initial examination and previous CT Scan findings, TMJ dislocation was diagnosed. In order to completely examine the patient, reduction of the jaw was attempted on chair side. The relocation of jaw was achieved by digital manipulation with little force and secured with Barton’s bandage to prevent from subsequent jaw dislocation.Family was counseled and explained method of reducing jaw and securing with Barton’s bandage if happens at home. After 24 hours, patient returned to ER with the same complaint. Although jaw dislocation was reduced again by applying minimal digital pressure and effort.Since patient was unable to eat, she was exhausted, distressed and admitted again under pediatric care for rehydration and medicalsupport. She was given tablet baclofen 2mg given 12 hourly, diazepam 5mg PR, paracetamol 250mg suppository. Patient was discharged after two days on oral medicines, with advice on cervical collar and bandage. The patient had two similar episodeswith
the same management. Patient’s family was counseledby nutritionist and psychiatrist.
All jaw dislocationsoccurred in Pakistan and resulted in admission three times. Following return to their country, no further episodesoccurred uptill the last follow up which was last week on phone. The pediatrician had continued tablet baclofen for 6 months.Patient was followed every month for 1 year, in Pakistan follow up visit in clinic and after their return to their country follow up on phone and internet call. Patient was still in contact till the last filing of the report.

DISCUSSION

The Temporomandibular joint is a synovial hinge-type joint, performs gliding and rotational movements.5 Dislocation refers to dislodgment of condylar part of the mandible out of glenoid fossa-base of the skull and over the articular eminence process, prevents to come in its normal position spontaneously.5,6 Simple reduction after dislocation is difficult if not manage immediately, this is due to masticatory muscles spasm.1,7 In children, irreversible dislocation does not occur because articular eminence is rudimentary until the end of first decade of childhood.5,8
If there was a history of trauma to the mandible, radiographs would be advised to exclude the possibility of condylar fractures resulting inan anterior open bite, this condition is similar to a mandibular jaw dislocation.In contrast, jaw dislocation must be addressed immediately, any delay in reduction of jaw dislocationwill more likely necessitate sedation or even general anesthesia for the reduction due to muscle fatigue and spasm as occurred in this case.The technique for the reduction of jaw dislocation is that the patient should be placed upright on a chair with head support.The operator standsin front, using both thumbs of handsplaced on last molar tooth of jaw. Force then should be applied in downward direction followed by backward and upward pull to achieve jaw reduction and occlude the teeth.Manual reduction, Bartons bandage, IMF screws with elastics, orthodontic brackets with elastics may be used on an outpatient setting. More invasive surgical procedures like Dautery procedure, intra-articular injections
(Botox, Triamcinolone, Autologous blood),11 eminectomy, use of hardware to augment the articular eminence.The potential risks associated with the surgical procedures are infection, failure of the procedure, plate or screw fracture, temporary or permanent facial nerve paralysis, multiple operationsand strong follow-up is required to prevent osteoarthrosis. In a growing child, there are risks specified to growth, growth center and possible osteoarthrosis.
The reported cases in the literature related to recurrent dislocations in pediatric are scarce. In 2000 Whiteman PJ et al, reported bilateral temporomandibular joint dislocation in 10-month-old infant after vomiting9 confirming on radiograph manually reduced the mandible by applying gentle pressure downward at the posterior and upward at the chin. In 2009 Cascarini L, reportedbilateral temporomandibular joint dislocation in 23-month-old infant after three episodes of vomiting, manual reduction was unsuccessful whilst the child was awake in the clinic but was achieved under general anesthesia.5 In 2015 Khilji MF et al, reported bilateral temporomandibular joint dislocation of a 26 months old child with no known familial or genetic disorder. Reduction was achieved by manual digital manipulation under procedural sedation. The child was able to close her mouth and was discharged home on oral paracetamol and chin to vertex bandage to restrict wide jaw opening and parental counseling.12
In 2017 Painatt JM et al, reported bilateral temporomandibular joint dislocation in 18-month-old infant after child’s mother forcefully fed the child led to this condition, manual reduction was achieved under sedation and Barton’s bandage applied to prevent recurrent dislocation.10 In 2018 Sicard L et al, reported chronic bilateral non traumatic temporomandibular joint dislocation in 26 months old and a 19 months old child in this management of dislocation was dealt by different means such as manual digital manipulationunder general anesthesia, chin-to-vertex bandage utilized in other episodes and orthodontic headgear utilization for securing joint under sedation also another maneuver to overcome recurrent TMJ dislocation.1
Clinicians have used different options to treat this distressing situation by using Barton’s bandage, use of headcap tied to gauze, use of soft paediatric collars to keep jaws closed.

CONCLUSION

This case emphasizes that recurrent dislocation of temporomandibular joint (TMJ) is a possibility in infants and children, although it is rare.Careful history and examination will reveal a possible cause for the dislocation. Conservative management, patient and family education and psychiatric evaluation will help in this distressing situation for the child and family.

CONFLICT OF INTEREST

None to declare

REFERENCES

1. Sicard L, O’Hana D, Khonsari RH, Brahim AK. Bilateral dislocation of the temporomandibular joint in children. J Oral Maxillofacial Surgery. 2018;76:2307-15. https://doi.org/10.1016/j.joms.2018.04.004
2. Akinbami BO: Evaluation of the mechanism and principles of management of temporomandibular joint dislocation. Systematic review of literature and a proposed new classification of temporomandibular joint dislocation. Head Face Med 7:10, 2011. https://doi.org/10.1186/1746-160X-7-10
3. Forshaw RJ: Reduction of temporomandibular joint dislocation:An ancient technique that has stood the test of time. Br Dent J218:691, 2015. https://doi.org/10.1038/sj.bdj.2015.438
4. Myrhaug H. A new method of operation for Habitual dislocation of the mandible: review of former methods of treatment. Acta Odontol Scand. 1951;9:247-61. https://doi.org/10.3109/00016355109012789
5. Cascarini L, Cameron MG. Bilateral TMJ dislocation in a 23-monthold infant: A case report. Dent update. 2009;36:312-3. https://doi.org/10.12968/denu.2009.36.5.312
6. Shorey CW, Campbell JH. Dislocationof the temporomandibular joint.Oral Surg Oral Med Oral Path Oral Radiol Endod. 2000;89:662- 68. https://doi.org/10.1067/moe.2000.106693
7. Gray AR, Barker GR: Idiopathic blepharospasm-oromandibular dystonia syndrome (Meige’s syndrome) presenting as chronictemporomandibular joint dislocation. Br J Oral Maxillofac Surg.29:97,1991. https://doi.org/10.1016/0266-4356(91)90090-R
8. Ogus HD, Toller PA. Common Disorders of the Temporomandibular Joint 2nd edn. Bristol: Wright, 1981.
9. Whiteman PJ, Pradel EC. Bilateral temporomandibular joint dislocation in a 10-month-old infant after vomiting. Pediatric emergency care. 2000;16:418-19. https://doi.org/10.1097/00006565-200012000-00011
10. Painatt JM, Veeraraghavan R, Puthalath U. Temporomandibular joint dislocation in an 18-month-old child. Contempo Clin Dent. 2017;8:155. https://doi.org/10.4103/ccd.ccd_1041_16
11. Tocaciu S, McCullough MJ, Dimitroulis G. Surgical management of recurrent TMJ dislocation- a systematic review. Oral Maxillofac Surg. 2019; 23:35-45. https://doi.org/10.1007/s10006-019-00746-5
12. MF Khilji, AKMalik. Bilateral temporomandibular joint dislocation in a 26-month-old child: A rare emergency. J Emerg Medi, Trauma and Acute Care. 2015; 2015:9. https://doi.org/10.5339/jemtac.2015.9

1. Consultant, Department of Oral and Maxillofacial Surgery, Aga Khan University Hospital, Karachi.
2. MS (Scholar), Registrar, Department of Oral and Maxillofacial Surgery, Baqai Dental College, Baqai Universit, Karachi, Pakistan.
Corresponding author: “Dr. Sharjeel Bashir” < drsharjeelbashir@yahoo.com >

Humayun Kaleem Siddiqui          BDS, FCPS

Sharjeel Bashir                              BDS

Laila Fawzi Baidas            BDS, FDS, MSc

INTRODUCTION

Papillon-Lefevre Syndrome (PLS) is a rare autosomal recessive disorder.1 It was first discovered in 1924 by French physicians Papillon and Lefevre. It is characterized by a palmoplantar hyperkeratosis, and early
onset of periodontitis in the deciduous and permanent dentitions.2
Reviews of the literature have focused on the syndrome’s genetic basis,3,4 as well as its periodontal management.5-6 It has been reported that consanguineous offspring have greater frequency of occurrence of the syndrome due to genetic predisposition. The prevalence of PLS is 1-4 cases per million people with no racial or sex predominance, and the carrier frequency appears to be 2-4 per thousand population.7
The identified genetic defect in PLS is located on chromosome 11q14.14.3 as a mutation of the cathepsin C gene.8 Previous studies showed that a 90% reduction of the cathepsin C gene causes a deficiency of cathepsin C enzymatic activity, resulting in reduced immunity and host response against bacteria.9,10 The cathepsin C gene is found in epithelial regions, keratinized oral gingiva, and various immune cells and their precursors.11 Even with these advances in recognizing the genetic predisposition of the syndrome, the pathogenesis leading to the periodontal involvement is still unclear.12
Dermatological signs develop before the age of 4 to 6 months and remain throughout the patient’s life. Common dermatological changes include well-demarcated erythematous hyperkeratotic lesions on the soles, the palms and the dorsum of the hand.7
Periodontitis could affect the primary and permanent dentitions resulting in premature tooth loss of both dentitions. Classically, eruption of the primary dentition into the oral cavity is accompanied by
severe gingival inflammation and subsequent rapid destruction of the periodontium. The early loss of teeth at the age of 4 results in decreased inflammation, and the gingiva appears to be healthy. Similarly, the eruption of the permanent teeth evokes a cycle of gingivitis and periodontitis accompanied by subsequent premature exfoliation in the early teenage years, resulting in alveolar bone loss and a decrease in facial height. Subsequently, after a period of tooth loss, the third molars erupt with no sign of inflammation.13
Because of the reduced immunity to pathogens in PLS patients, Actinobacillus actinomycetemcomitans (Aa) and other anaerobic bacteria have been proven to play a major role in the periodontitis.6 An improvement in clinical symptoms has been observed with synchronized elimination of Aa from the gingival crevice and the use of a systemic antibiotic.3
The conventional treatment measures for periodontal disease are usually unsuccessful in controlling periodontal disease associated with the syndrome.14 Previous studies have shown that at the active stage of periodontitis, it is possible to arrest further periodontal destruction with early treatment and preventive measures.15-17 These comprise oral hygiene instruction, the use of mouthwashes, frequent scaling and debridement, the use of planned multiple systemic antibiotic regimens, periodontal surgery, and extraction of hopeless teeth.18 Limited information is available in the literature regarding combined treatment of orthodontic tooth movement and periodontal treatment.15-17 To our knowledge, the cases presented here are two of the few cases to be published about combined periodontal-orthodontic treatment for patients with PLS. The aim in presenting these cases is to demonstrate the possibility of creating space for the permanent teeth to erupt, and of stabilizing the occlusion in young PLS patients until they reach full arch development under a strict periodontal treatment protocol.

CASE REPORTS

The two cases presented were treated in the periodontics and orthodontic clinics, at the College of Dentistry, King Saud University, Riyadh, Saudi Arabia. for clarification, the cases are numbered as 1 and 2.

CASE 1

A 10-year-old male patient was referred for evaluation of his missing teeth and periodontal condition. His family history revealed consanguineous marriage of the parents. He was the third child born to the family. His elder sisters and younger brothers were free of apparent genetic defects, but the youngest sister also had PLS. The patient’s medical history revealed that symptoms started at the age of 4 months in the form of desquamation and erythema on the hands and feet. Plaques with pustules and a purulent discharge were observed when he started walking. Treatment, including cleaning of the lesions and systemic antibiotics, was undertaken at the Department of Dermatology at King Faisal Specialist Hospital. Blood tests including a complete blood count, blood chemistry profile, and liver function tests returned normal results. A genetic test followed by fluorescent Sanger sequencing of exons 3 to 7 of the cathepsin C gene revealed a mutation. The diagnosis of PLS was confirmed from the clinical symptoms and the genetic test. The dental
history revealed that the deciduous teeth had erupted at the normal age (6 months), but the patient experienced inflamed and swollen gingiva after eruption, pain with mastication, and mobility followed by spontaneous loss of the teeth. At the age of 3 years, the second primary molars were the only deciduous teeth remaining without any root resorption. At the time of referral to the orthodontic clinic, intraoral examination revealed that the patient was in the early mixed dentition stage, with mild gingival inflammation and bleeding on probing, and no mobility was observed. The panoramic radiograph revealed slight horizontal alveolar bone loss, congenitally missing bilateral lower second premolars, a large restoration in the lower left first molar, and a lack of space for the permanent dentition. The patient complained
of pain in the lower left first molar during eating, and the panoramic radiograph confirmed the presence of a periapical lesion. Accordingly, the patient was referred for root canal treatment and restoration (Figure 1).

Fig 1: Pretreatment clinical photographs and panoramic radiograp

A strict periodontal regime was investigated by the periodontist. Anti-infective therapy was started as the initial phase, consisting of oral hygiene instruction, supragingival and subgingival scaling, and rinsing with 0.2% chlorohexidine mouthwash twice daily. Subgingival plaque samples of the periodontally affected teeth were taken for microbiological investigation to detect the presence of Aa. Systemic amoxicillin (25 mg twice/day) and metronidazole (250 mg three times/day) were prescribed for 2 weeks. The maintenance program was continued during the orthodontic treatment, including oral hygiene instruction and oral prophylaxis once every 4 to 6 weeks, depending on the oral hygiene condition of the patient.17 At the age of 10 years a lower lingual arch and an upper Nance appliance were used to maintain space for the permanent teeth and prevent further movement of the posterior teeth into the edentulous area. At the age of 13 years, the patient presented with a class I malocclusion on a skeletal class I pattern with a normal vertical relationship, a straight profile with a symmetrical face, and competent lips. The dental characteristics were a class I molar relationship, a class II canine relationship, an overbite of 80%, and a 4 mm overjet that indicated a class I malocclusion. The upper incisors were in normal inclination on the basal bone, and the lower incisors were slightly retroclined. The lower right and left second premolars were congenitally missing, and the lower right and left second deciduous molars were retained. The lack of space for the upper and lower first premolars was readily detected, with -5 mm of crowding in the lower dentition, and -3 mm of crowding in the upper dentition (Figure 2).

Fig 2: Pretreatment cast photographs and panoramic radiograph before start of orthodontic treatment

ORTHODONTIC OBJECTIVES AND MANAGEMENT

The primary objectives of treatment were to correct the anterior deep bite, taking advantage of alveolar growth changes in the premolar-molar area. The other objectives included relieving crowding and creating space in the upper and lower arches, maintaining the lower deciduous second molars, achieving class I canine and molar relationships, and last stabilizing the occlusion. Preadjusted edgewise fixed orthodontic appliances (0.22″ slot Roth prescription) were bonded in the lower jaw, and then the upper jaw. Orthodontic treatment was begun in only one jaw with very light force because of periodontal condition. The main problems in the lower jaw were moderate crowding, deficient space for the lower first premolars, a retained deciduous second molar, congenitally missing second premolars, and overeruption and retroclination of the lower incisors. From the periodontal viewpoint, the incisors, canines, and first molars exhibited minimal or no bone loss, and had a good prognosis because of their later eruption with the concomitant periodontal treatment. Overbite reduction was regarded as a major orthodontic treatment goal, so a 016 × .022 beta-titanium (TMA) utility arch was used to open the deep bite and create an incisal stop. Intrusive forces were kept at very low levels (approximately 10-15 gm). Initial alignment and leveling were achieved with 0.016″ copper nickel titanium (Cu-NiTi) archwire, followed by 0.016, 0.018, and 016 × .022 stainless steel (SS) archwires.
The space for the lower first premolars was created through interdental stripping and the use of a NiTi push-coil spring between the canine and the deciduous second molars. In the upper jaw, the main problem was mild crowding, and slight overeruption of the upper incisors. Therefore, alignment and leveling were completed with 0.016″ Cu-NiTi wire, and excessive eruption of the upper incisors was corrected with
continuous archwire mechanics from molar to incisor using 0.016, 0.018, and 0.016 × 0.022 SS archwires. Crowding of the upper arch would thereafter be resolved by subsequent interdental stripping between the posterior teeth (Figure 3).

Fig 3: Clinical photographs and panoramic radiograph after a year of treatment

The total treatment duration was 24 months. Before the fixed appliances were debonded, a good functional occlusion had been established. The lower left deciduous second molar exfoliated because of root resorption. Hawley retainers were used for retention; the upper Hawley retainer included a biteplate to control vertical growth, while the lower Hawley retainer had an acrylic tooth in the edentulous space. The protocol for retention was full-time use of the retainers for 3-4 months, followed by night-time use for several years to control the vertical overlap of incisors. However, the lower Hawley retainer was to be used full time until he was ready for replacement of the missing second premolars with implants. The treatment aims were accomplished successfully

Fig 4: Post-treatment clinical photographs and panoramic radiograph

The deep bite was corrected, and normal overjet and overbite were achieved. The canine relationship was corrected to a class I relationship, the Angle class I molar relationship was maintained, and the midline of the upper and lower arches was corrected. The panoramic radiograph showed minimal bone loss in both jaws, and vertical bone loss at the distal surface of the lower left first molars. The distal root of the lower right deciduous molar was resorbed, but the tooth was still stable with no mobility. Our aim was to retain the deciduous tooth for as long as possible until it could be replaced with an implant (Figure 4). The patient exhibited

Fig 5: Clinical picture of the foot and hands showing hyperkeratosis of the palms and soles

hyperkeratosis of the palms of the hand and the soles of the feet, but these skin lesions subsided with age (Figure 5). Post-treatment evaluation after 3 years revealed some relapse of the overbite because the patient was not cooperative in wearing the retainers. An OPG revealed no bone loss compared with the previous OPG after debonding. The space of tooth #35 had decreased as a result of drifting of the lower left first molar (Figure 6).

Fig 6: 3-year post-treatment clinical photographs and panoramic radiograph

CASE 2

A female patient aged 8 years diagnosed with PLS was referred to the periodontics clinic by her primary care practitioner. She was the second child of consanguineous unaffected parents. Her elder brother also had PLS, but the other three siblings were free of apparent genetic defects. The patient’s medical history revealed that desquamation and erythema of the palms and soles were observed at the age of 4 months, with a gradual onset, followed by thickening and fissuring of both the soles. These symptoms worsened with age. The patient presented at the dermatology clinic at the National Guard Hospital, Riyadh, Saudi Arabia, when she was 2 years old with a chief complaint of palmoplantar hyperkeratosis. All laboratory tests, including hematological and liver function tests, were normal. Various therapies were undertaken to treat the skin lesions with no improvement.

Accordingly, the patient was referred to the pediatric genetic department for further investigation. The dental history revealed that during the first year after eruption of the incisors, the gingiva had become inflamed and swollen with a purulent discharge in response to the pressure of mastication. The deciduous teeth erupted with normal sequence and timing. At the age of 4 years, all the deciduous teeth were extracted under general anesthesia, aiming for complete recovery of the gingiva to its normal healthy status. Taking into consideration the clinical features, laboratory investigations, and genetic testing, a diagnosis of PLS was confirmed by the patient’s pediatrician.
The same protocol for periodontal management as for the previous patient was followed. The patient was subsequently referred to the orthodontic clinic. Intraoral examination revealed gingival inflammation, and no tooth mobility. She was in the mixed dentition stage, with a deep overbite (more than 50%) and a lack of space for the permanent dentition. A panoramic radiograph revealed space loss and mesial drifting of the first molars (Figure 7). At the

Fig 7: Pretreatment clinical photographs and panoramic radiograph

age of 9 years space maintainers were used in the form of a lower lingual arch and an upper Nance appliance to maintain the space for the permanent teeth to erupt and to prevent further movement of the posterior teeth into the edentulous area. Regular checks and follow-ups were maintained every 3-6 months until the permanent teeth erupted. At the age of 14 years, the patient presented with class I malocclusion with a skeletal class I pattern and a normal vertical relationship, with mild crowding in the upper arch and moderate crowding in the lower arch, a Class I molar and canine relationship, and a 2-mm lower midline shift to the left side. The panoramic radiograph revealed generalized horizontal bone loss, a vertical pocket distal to the lower right and upper left first molars, and mesial drifting of the lower Left first molars. She was in the permanent dentition stage, with all teeth erupted except the lower second premolars and third molars. Root dilaceration was present in many of

Fig 8: Pretreatment cast photographs and panoramic radiograph before start of orthodontic treatment

the teeth, but the dilaceration was more severe in the right upper lateral and right lower lateral teeth as compared with upper second premolars and upper left lateral incisor. The lack of space for the lower second premolars was readily detected, with -5 mm of crowding in the lower dentition

Fig 9: Clinical picture of the Face showing hyperpigmentation around the mouth, and Palm-planter hyperkeratosis of the hand and foot

and +3 mm of spacing in the upper dentition (Figure 8). The patient exhibited hyperkeratosis of the palms and soles, and dryness and around the mouth (Figure 9).

ORTHODONTIC OBJECTIVES AND MANAGEMENT

The objectives of the treatment were to relieve the crowding in the lower arch, create space for the permanent teeth, achieve class I canine and molar relationships, close spaces, and stabilize the occlusion. Preadjusted edgewise fixed orthodontic appliances (0.22″ slot Roth prescription) were bonded in the lower jaw, and then the upper jaw. A very light force was used throughout the orthodontic treatment. Initial alignment and leveling were achieved with a maxillary 0.016″ Cu-NiTi archwire, followed by 0.016, and 0.016 ×0.022 SS wire. The main problems in the lower jaw were moderate crowding and deficient space for the lower second premolars. From the periodontal viewpoint, the erupted teeth exhibited minimal bone loss, except for the lower right and left first molars, which had distal vertical pockets. Hence, the planned treatment goals were expanding the arch and creating enough space for eruption of the premolars, and stabilizing the occlusion. The spaces for the lower first premolars were achieved with interdental stripping and push coil springs (Figure 10). A class II elastic was used to correct the occlusion on the left side, and anterior cross elastics were applied to correct the lower midline. The OPG

Fig 10: Clinical photographs and panoramic radiograph after a year of treatment

revealed no bone loss and no further increase in the distal vertical pocket of the lower first molars.
The total treatment duration was 15 months. The treatment goals were accomplished, and a good functional occlusion was established. The treatment resulted in a normal overjet and overbite, and class I canine and molar relationships. A panoramic radiograph showed no or only minimal bone loss (Figure 11). During the whole period of orthodontic treatment, the patient’s periodontal status was regularly evaluated for bleeding on probing, attachment loss, and pocket depth.

Fig 11: Post-treatment Clinical photographs and panoramic radiograph

Fig 12: 3-year post-treatment panoramic radiograph

Retention was accomplished by using a fixed lingual canine-to-canine retainer in the lower arch and a Hawley retainer in the upper arch. A 3-year post-treatment OPG was taken to document the stability of the periodontal condition, and showed no further resorption of bone (Figure 12).

DISCUSSION

The etiology of the periodontal problems in PLS patients is not clearly understood. The increased prevalence of periodontal disease in PLS patients gives credence to the hypothesis that an underlying immunological deficiency is an important etiological factor causing periodontitis in PLS patients.7
This results in a reduced host response against plaque bacteria and increased susceptibility to infection.19 Aa and Gram-negative bacteria were detected in subgingival plaque, and were found to play a significant role in the etiology of PLS periodontitis.6 Patients with affected periodontal tissue are at high risk of further breakdown and loss of teeth.7
Early diagnosis and proper management of periodontal problems helps to minimize periodontal deterioration and the undesirable sequelae of the syndrome.
Periodontal therapy includes mechanical debridement by scaling and polishing, systemic antibiotics to eliminate the pathogen reservoir, extraction of hopeless mobile teeth, maintenance of good oral hygiene, and regular monitoring and recall appointments.12,19 Eradication of subgingival Aa and maintenance of good oral hygiene are key factors in in preserving permanent teeth in young PLS patients.18,20 In our reported cases, the therapeutic approaches for the primary dentition period were different. In the first case, all the primary teeth except the lower second molars exfoliated several months after eruption. A combination of systemic amoxicillin and metronidazole in addition to the maintenance of good oral hygiene was followed; this has been successful in some cases.5
Another therapeutic approach to PLS, which was followed in the second reported case, was to eradicate the pathogenic periodontal flora by extracting all the primary teeth before eruption of the permanent teeth, combined with systemic antibiotic treatment to create a safe environment for eruption of the permanent teeth. The edentulous period combined with meticulous oral hygiene determines the treatment outcome.20
After the edentulous period, the permanent teeth erupt without any guidance, and this can lead to loss of space, crowding, and collapse of the dental arch.15 The cases reported here have demonstrated the potential for successful orthodontic treatment of PLS patients under a controlled regime of periodontal treatment. Orthodontic treatment was performed to expand the arch, create space for the normal eruption of the permanent teeth, and stabilize the occlusion.
This treatment helps patients to gain a normal facial appearance rather than the collapsed appearance caused by early loss of teeth.15,20 Orthodontic treatment in PLS patients with periodontal disease poses a high risk of exacerbating periodontal breakdown and tooth loss.13 In the literature, information about orthodontic treatment in PLS patients is limited. However, there are several reported cases in which follow-up of well-planned orthodontic treatment combined with a periodontal regimen resulted in successful maintenance of a healthy dentition.15-17 In the present case reports, the patients were in the late mixed dentition period with mild to moderate crowding along with mild generalized bone loss and a deep overbite. A deep overbite is traumatic to gingival tissue, and could cause occlusal trauma to the upper anterior teeth and loss of periodontal support.21,22 Light force and moderate orthodontic tooth movements of up to 3 mm were used over the entire treatment period with good maintenance of oral hygiene. The treatment resulted in well-aligned arches with acceptable occlusion and no or only minimal bone loss. The panoramic radiographs taken at the end of treatment showed a stable periodontal condition with no bone loss. Evaluation at 3 years post-treatment revealed good stability with retention. In the first case, there was some relapse of the overbite because the patient was not cooperative in wearing the retainers, or because
vertical growth continued into the late teens. However, in the second case, the result was stable.
These case reports showed the need to discuss the possibility of orthodontic tooth movement in patients with PLS. More research and case reports are needed to document treatment in patients with PLS of varying severity levels. However, the present case reports revealed that orthodontic tooth movement is possible in patients with PLS within a combined interdisciplinary treatment protocol.

CONCLUSION

The present case reports demonstrate that PLS patients can undergo successful combined orthodontic treatment and strict periodontal therapy to achieve moderate orthodontic tooth movement. Such a combined interdisciplinary treatment regimen could be crucial in achieving functional and esthetically pleasing dentition in patients with PLS.

ACKNOWLEDGEMENTS

The author appreciatively acknowledges Prof. Nahid Ashri, Consultant Periodontist, Department of Periodontics and Community Dentistry, College of Dentistry, King Saud University, Riyadh, for her valuable and competent support and advice. We also thank Helen Jeays, BDSc AE, from Edanz Group (https://en-author-services.edanzgroup.com/ac) for editing a draft of this manuscript.

CONFLICT OF INTEREST

None to declare

REFERENCES

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2. Sharma A, Kaur G, Sharma A. Papillon-Lefevre syndrome: A case report of 2 affected siblings. J Indian Soc Periodontol. 2013;17:373-77. https://doi.org/10.4103/0972-124X.115643
3. Ullbro C, El-Samadi S, Boumah C, Al-Yousef N, Wakil S, Twetman S, et al. Phenotypic variation and allelic heterogeneity in young patients with Papillon-Lefèvre syndrome. Acta Derm Venereol. 2006;86:3-7. https://doi.org/10.1080/00015550510011619
4. de Haar SF, Tigchelaar-Gutter W, Everts V, Beertsen W. Structure of the periodontium in cathepsin C-deficient mice. Eur J Oral Sci. 2006;114:171-73. https://doi.org/10.1111/j.1600-0722.2006.00344.x
5. De Vree H, Steenackers K, De Boever JA. Periodontal treatment of rapid progressive periodontitis in 2 siblings with Papillon-Lefèvre syndrome: 15-year follow-up. J Clin Periodontol. 2000;27:354-60. https://doi.org/10.1034/j.1600-051x.2000.027005354.x.
6. Eickholz P, Kugel B, Pohl S, Näher H, Staehle HJ. Combined mechanical and antibiotic periodontal therapy in a case of PapillonLefèvre syndrome. J Periodontol. 2001;72:542-49. https://doi.org/10.1902/jop.2001.72.4.542
7. Hart TC, Shapira L. Papillon-Lefèvre syndrome. Periodontol 2000. 1994;6:88-100. https://doi.org/10.1111/j.1600-0757.1994.tb00029.x
8. Hart PS, Zhang Y, Firatli E, Uygur C, Lotfazar M, Michalec MD, Marks JJ, Lu X, Coates BJ, Seow WK, Marshall R. Identification of cathepsin C mutations in ethnically diverse Papillon-Lefèvre syndrome
   patients. J Med Genet. 2000;37:927-32. https://doi.org/10.1136/jmg.37.12.927
9. Toomes C, James J, Wood AJ, Wu CL, McCormick D, Lench N, Hewitt C, Moynihan L, Roberts E, Woods CG, Markham A. Loss-offunction mutations in the cathepsin C gene result in periodontal disease and palmoplantar keratosis. Nat Genet. 1999;23:421-24. https://doi.org/10.1038/70525
10. Oguzkurt P, Tanyel FC, Büyükpamukçu N, Hiçsönmez A. Increased risk of pyogenic liver abscess in children with Papillon-Lefevre syndrome. J Pediatr Surg. 1996;31:955-56. https://doi.org/10.1016/S0022-3468(96)90420-0
11. Hart TC, Hart PS, Bowden DW, Michalec MD, Callison SA, Walker SJ, Zhang Y, Firatli E. Mutations of the cathepsin C gene are responsible for Papillon-Lefevre syndrome. J Med Genet. 1999;36:881-87.
12. Hattab FN. Papillon-Lefèvre syndrome: from then until now. Stomatological Dis Sci. 2019;3:1 https://doi.org/10.20517/2573-0002.2018.22
13. Dhanrajani PJ. Papillon-Lefevre syndrome: clinical presentation and a brief review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108:e1-7. https://doi.org/10.1016/j.tripleo.2009.03.016
14. Nickles K, Schacher B, Schuster G, Valesky E, Eickholz P. Evaluation of two siblings with Papillon-Lefèvre syndrome 5 years after treatment of periodontitis in primary and mixed dentition. J
    Periodontol. 2011;82:1536-47. https://doi.org/10.1902/jop.2011.100615
15. Lux CJ, Kugel B, Komposch G, Pohl S, Eickholz P. Orthodontic treatment in a patient with Papillon-Lefèvre syndrome. J Periodontol. 2005;76:642-50. https://doi.org/10.1902/jop.2005.76.4.642
16. Challa P, Gandikota CS, Tarlapally S, Rayapudi N. Combined orthodontic and periodontic therapy in a patient with Papillon-Lefèvre syndrome. Journal of Dr. NTR University of Health Sciences.
    2012;1:182-86. https://doi.org/10.4103/2277-8632.102450
17. AlSarheed MA, Al-Sehaibany FS. Combined orthodontic and periodontic treatment in a child with Papillon Lefèvre syndrome. Saudi Med J. 2015;36:987-92. https://doi.org/10.15537/smj.2015.8.11437
18. Rüdiger S, Petersilka G, Flemmig TF. Combined systemic and local antimicrobial therapy of periodontal disease in Papillon-Lefèvre syndrome. A report of 4 cases. J Clin Periodontol. 1999;26(12): 847-854.
19. 23.Yousry YM, Abd EL-Latif AE, Abd El-Gawad RY. Case Report: Clinical manifestation and dental management of Papillon-Lefèvre syndrome. F1000Res. 2018;7:1420-8. https://doi.org/10.12688/f1000research.16042.1
20. Toygar HU, Kircelli C, Firat E, Guzeldemir E. Combined therapy in a patient with Papillon-Lefèvre syndrome: A 13-year follow-up. J Periodontol. 2007;78:1819-24. https://doi.org/10.1902/jop.2007.070004
21. Bennett JC, McLaughlin RP. Management of deep overbite with a preadjusted appliance system. J Clin Orthod1990;24:684-96.
22. Tulloch JC, Proffit WR, Phillips C. Outcomes in a 2-phase randomized clinical trial of early Class II treatment. Am J Orthod Dentofacial Orthop. 2004;125:657-67. https://doi.org/10.1016/j.ajodo.2004.02.008

Consultant and Associate Professor, Department of Pediatric Dentistry and Orthodontics, College of Dentistry, King Saud University, Saudi Arabia.
Corresponding author: “Dr. Laila Fawzi Baidas” < lbaidas@ksu.edu.sa >

Laila Fawzi Baidas            BDS, FDS, MSc

Papillon-Lefevre syndrome (PLS) is a rare autosomal recessive disorder characterized by palmoplantar hyperkeratosis and early onset of severe destructive periodontitis causing premature loss of both deciduous and permanent dentitions at a young age. In this article two cases of patients with Papillon-Lefevre syndrome in late mixed dentition are presented. The objective of these case reports was to illustrate that under a controlled regime of periodontal treatment, orthodontic treatment is possible in patients with Papillon-Lefevre syndrome. In both cases, the deciduous dentition was lost prematurely shortly after eruption. The permanent teeth erupt without any guidance, and this can lead to loss of space, crowding, and collapse of the dental arch. The aim of the treatment was to expand the arch, create space to allow normal eruption of the permanent teeth, and stabilize the occlusion to help the patient achieve a normal facial appearance rather than the collapsed appearance caused by early extractions.
KEYWORDS: Papillon-Lefevre Syndrome, Orthodontics, Mixed dentition, Case reports
HOW TO CITE: Baidas LF. Orthodontic treatments of papillon-lefevre syndrome: Two case reports. J Pak Dent Assoc 2021;30(2):132-138.
DOI: https://doi.org/10.25301/JPDA.302.132
Received: 25 November 2020, Accepted: 01 February 2021
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Farhan Raza Khan             BDS, MS, MCPS, FCPS

The term ‘fellowship’ is fairly common among medical and dental graduates especially those aspiring to become subject specialists. However, there are so many meanings and construct of this term that not only patients but even students get confused. The following description explains what fellowship is all about and what its types are; Actually, fellowship has following meanings:-

FELLOWSHIP AS A HIGHER CLINICAL DIPLOMA

Traditionally, fellowship is the name of the higher clinical examination administered by the royal colleges in the UK (London, Edinburgh & Glasgow) and Ireland (Dublin). These colleges (their nominated examiners in the specialist faculty) confer the higher diplomas to the candidates who have completed their structured training at approved posts and have successfully pass the high-end written and oral examination as a terminal qualification and thus admitted into the college fellowship.1 Diplomas such as FRCS, FRCSI, FRCP, FRCA, FRCPath, FDSRCS or FFDRCSI are some examples. Although specialty FDS is the exit level examination in UK and Ireland, recent changes in the nomenclature in UK, have made the specialty membership examination in dental disciplines as the exit level examination.
In Pakistan, the College of Physicians and Surgeons (CPSP) follows the British model and confers FCPS diploma to the candidates who fulfill all the requirements including residency training, workshops, logbook, written examination, OSCE and oral examination plus approval of a dissertation or two papers published in indexed journals (Index Medicus), as first or second author, in lieu of the dissertation.2
The protocols of the papers must be approved by the Research training and monitoring cell at the CPSP before initiation of the study. Other reputable colleges such as The College of Physicians & Surgeons in Bangladesh, Royal College in Canada and, The Royal Australasian College of Dental Surgery award their respective fellowship diploma on similar grounds as done in Ireland.

FELLOWSHIP AS A HIGHER DIPLOMA IN EDUCATION

Some institutions confer fellowship upon completion of higher training or achieving excellence in education. These include the well-known FAIMER (Foundation for the Advancement of International Medical Education & Research) offered by ECFMG in the USA.3 Similarly, a fellowship pertaining Fellowship in Dental Education is conferred by the faculty of dental trainers at the Royal College of Surgeons abbreviated as FDT RCSed.4

HONORARY FELLOWSHIP AS A TOKEN OF APPRECIATION

On certain exceptional grounds, the terms of reference of the royal colleges (or even CPSP) allow them to award their fellowship diploma without examination to any eminent senior clinician/politician/artist or social worker as a token of recognition of service in the public domain. It’s mandatory to write the term “honorary” with such diplomas.5 it’s interesting to note that there is no policy available to the public as to who will be entitled to the honorary fellowships. Mostly, it’s the discretion of the council and the president of the college to confer this honor to the guest at the convocation.

FELLOWSHIP AS AN ADMISSION TO A REPUTABLE SCIENTIFIC SOCIETY/ ACADEMY

The Royal Society (UK) fellowship falls into this category. There is no examination involved in this fellowship. Annual election or nomination of very few select individuals belonging to medicine, natural science
or mathematics are given this fellowship honor on their outstanding merit and contributions to the advancement of science.6
These fellows are the most eminent scientists and researchers in their respective disciplines. Names such as Isaac Newton, Charles Darwin, Albert Einstein, Francis Crick and Stephan Hawking are some examples. So far, only a few Pakistanis have received this fellowship. These include well-respected names such as Dr Salimuzzaman Siddiqui, Dr Abdul Salam, Dr Muhammad Akhter, Dr Atta ur Rehman and Dr Zulfiqar Bhutta. The American equivalent of such award is called the Membership of the National Academy of Sciences.

FELLOWSHIP AS A MISNOMER FOR PROFESSIONAL MEMBERSHIP

A number of professional societies, associations and academies use the term fellowship in lieu of membership for their members7. These are professionals who have demonstrated affiliation with the professional body for the specified time period with some additional requirements of submitting clinical cases/ demonstrating skills and knowledge. However, residency training is not an essential requirement for such a fellowship. Similarly, these fellowships don’t account for academic appointments or promotion on professorial rank. Outstanding contribution to the discipline of practice is not a requirement. Examples are fellowships in the Academy of Maxillofacial Prosthetics, Academy of Implant Dentistry or American Association of Oral Maxillofacial Surgeons etc.

FELLOWSHIP AS TUITION WAIVER

In North America, (USA and Canadian) universities use the term fellowship synonymous with the scholarship.8 This is especially true for graduate programs where students who get a tuition fee waiver or scholarship or any freeship / bursary are called as students on fellowship. Usually, these students are given this waiver on their merit/ past academic performance.

FELLOWSHIP AS POST-RESIDENCY CLINICAL TRAINING PROGRAM

Hospitals in USA frequently use the term fellowship training for those post graduate trainees who have already done their primary clinical residency training and now are admitted into the sub-specialty/ super specialty training.9 For example, a fresh Urology graduate might want to do a fellowship in prostate cancer or a nephrologist would pursue fellowship training in renal transplant unit. In dentistry, post-residency fellowships are presently non-existent but there will be a time in future where some Prosthodontists would do training in Maxillofacial Prosthodontics, Operative/Endodontists in Microsurgical Endodontics, Orthodontist in Lingual Orthodontics and Oral Surgeons would pursue fellowship in Orthognatic Surgery etc.

FELLOWSHIP AS POST-DOCTORAL RESEARCH TRAINING PROGRAM

The formal research training after acquiring a Ph.D. is called post-doctoral fellowship. 10 Most of these post-doctoral fellowships are paid by the host institution. An example would be one offered by National Institute of Health (NIH) that provides funding for postdoc fellowships. During this period, a post doc fellow advances his/ her research work, refines research questions and learn new methods and publishes in journal to gradually become an independent researcher.

CONFLICT OF INTEREST

None to declare

REFERENCES

1- https://www.rcsed.ac.uk/the-college/about-us
2- https://www.cpsp.edu.pk/fcps.php
3- https://www.faimer.org/about.html
4- https://fdt.rcsed.ac.uk/how-to-join/membership-categories
5- https://www.rcsed.ac.uk/news-public-affairs/news/2014/
april/world-renowned-head-and-neck-cancer-surgeon-to-receivehonour-from-rcsed
6- https://royalsociety.org/fellows/
7- https://www.aaoms.org/become-a-member/applyonline/fellowmember
8- https://grad.illinois.edu/gradhandbook/2/chapter7/tuitionwaivers#fellow
9- https://college.mayo.edu/academics/residencies-andfellowships/maxillofacial-prosthetics-and-dental-oncology-fellowshipminnesota/
10- https://www.humboldt-foundation.de/web/humboldt-fellowshippostdoc.html

Associate Professor, Operative Dentistry, Chief of Dental Services, Aga Khan University Karachi, Pakistan.
Corresponding author: “Dr. Farhan Raza Khan” < farhan.raza@aku.edu >

Farhan Raza Khan             BDS, MS, MCPS, FCPS

The term ‘fellowship’ is fairly common among medical and dental graduates especially those aspiring to become subject specialists. However, there are so many meanings and construct of this term that not only patients but even students get confused. The following description explains what fellowship is all about and what its types are. Actually, fellowship has eight different meanings.
KEYWORDS: Fellowship; award; examination; diploma
HOW TO CITE: Khan FR. What is Meant by Fellowship and What are its Types?. J Pak Dent Assoc 2021;30(2):130-131.
DOI: https://doi.org/10.25301/JPDA.302.130
Received: 12 May 2020, Accepted: 25 February 2021
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Samra Asif

Hassaan Bin Babar

Fatima Kamal

Kanwal Sohail

Amber Kiyani              BDS, M.Phil

INTRODUCTION

Panoramic radiography or orthopantomogram (OPG) is a dental radiograph that captures the maxillofacial region in a single image. This radiograph allows a quick assessment of the dental arches for tooth-related
problems, fractures, cysts and tumors.1
The anatomical landmarks clearly visible in the OPG include the nasal bone, maxillary sinus, maxillary bone, mandible, styloid process, temporomandibular joint, alveolar bone, and cervical vertebrae.2 Studies have shown that variations in the anatomical landmarks exist between populations. For example, the length of styloid process can from range between 20 to 32 mm, variations are noted in different races, gender, age groups, and even within the same individual. Similarly, changes in the shape of coronoid and condylar processes of the mandible, and location of inferior alveolar canal and mental foramen have also been documented.3-11 The importance of these variations is predicated on the fact that although they anatomically differ from the perceived traditional presentation, they usually do not require therapeutic intervention. They can, however, present diagnostic dilemma for the untrained eye or may cause symptoms. The asymptomatic nature of these findings remains the reason they are undetected and revealed incidentally on radiographs taken for other ailments.5,11 Although literature is available from other countries, documentation of radiographic changes in the Pakistani population is insufficient.
The purpose of this investigation was to determine the prevalence of anomalies and pathologies on OPGs taken for routine dental care at a dental teaching hospital. Our results will be important in establishing baseline statistics for the Pakistani population and familiarize Pakistani dentists with common radiographic changes. They will also be able to identify pathological entities that require medical attention.

METHODOLOGY

This study was approved by the Ethical Review Board at Riphah International University, Islamic International Dental College (IIDC/IRC/2020/06/04). A retrospective, cross-sectional study was designed to
evaluate OPGs. OPGs taken for routine dental care from February 2018 to April 2019 at Islamic International Dental Hospital were conveniently sampled. Visually clear images distinctly exhibiting all required anatomical landmarks were included for evaluation. All blurred, over exposed, underexposed images were excluded from the sample. Patient identifiers were removed before dissemination of information.
The landmarks were categorized under alveolar bone, mandible, maxilla, styloid process, maxillary sinus, nasal bones, inferior alveolar canal and condyle. Record of all radio-opaque and radiolucent changes was made. Alveolar bone loss was noted. Any significant change in shape and size of the structures was also highlighted. The position and displacement of the condyle, if any, were recorded. Elongation of styloid process and maxillary sinus lining was also noted.
The entire data set was analyzed by three dental students independently and verified by a radiologist. All anomalies and abnormalities identified on OPGs were recorded and analyzed using Statistical Packages for Social Sciences version 22. Data analysis was done by calculating frequencies and percentages for all anomalous and pathologic findings. These were represented in the form of tables, charts or  graphs.

RESULTS

Out of total 2,411 radiographs taken, 2,326 records satisfied the inclusion criteria. Of these 955 subjects were male (41.1%) and 1371 were female (58.9%). Patients were aged between 3-93 years with mean age of 29.06±17.79 years.

MAXILLARY SINUS

Nine hundred and thirteen (36%) OPGs were found to be normal with no anomalous or pathologic findings. Abnormal findings were noted in 1,498 (64%) from 2,326 radiographs. These included:

• Excess pneumatization of the maxillary sinus (MSP) was seen in 228 (9.8%) bilaterally. Unilaterally the MSP on the left side only was seen in 59(2.5%) and on theright side in 25 OPGs (1.1%).
• Radiopacities were noted in 64 (2.7%) OPGs, this included 38 (1.6%) in the left sinus and 29 on the right (1.2%).
• Corticated radiolucencies and radiopacities were seen in 29 (1.2%) OPGs, 17 (0.7%) on the left and 15 (0.6%) on the right.
• Fractures of the sinus were seen on 2 radiographs.
• For a total of 6 (0.03%) patients, the boundary of the sinuses was not intact.

Figure 1: Distribution of maxillary sinus anomalies and abnormalities

NASAL BONE

Two thousand one hundred and ten OPGs (86%) showed no significant changes in the nasal bone. The remaining 216 (8.3%) OPGs showed:

• Deflected nasal septum in 198 (7.5%) OPGs.
• Radiolucent lesions on 8 (0.3%) radiographs.
• Radio-opaque lesions in 7 (0.3%) cases.
• Three (0.1%) radiographs showed discontinuity of the nasal septum, this feature is indicative of fracture of nasal bone.

ALVEOLAR BONE LEVEL

We noted normal alveolar bone levels in 1,462 (55.7%) OPGs, 6 (0.3%) patients were edentulous and the remaining 943 (36%) exhibited:

• 798 (30.4%) OPGs showed generalized alveolar bone loss.
• 60 (2.3%) showed localized alveolar bone loss.

CONDYLE OF MANDIBLE

From 4,648 condyles evaluated, 916 (19.7%) appeared to be anteriorly displaced while 3,636 (78.2%) were concentric.

STYLOID PROCESS

The styloid process was evaluated on 2,326 OPGs. In 282 (12.1%) elongation of the styloid process was seen. The patterns of elongation were as follows:

• 21 (0.8%) showed unilateral elongation.
• 261 (9.9%) showed bilateral elongation.

Figure 2: OPG showing elongated styloid process

INFERIOR ALVEOLAR CANAL

OPGs from 2381 (99%) patients showed no pathological changes in association with the inferior alveolar canal. The remaining 30 (1%) OPGs showed:

• Radiolucencies in 5 (0.2%) cases.
• Radiopacities in 5(0.2%) OPGs
• 20 (0.9%) OPGs with dilated canal.

JAWS (MAXILLA AND MANDIBLE)

Radiopacities:
OPGs revealed presence of well-defined, roughly spherical-shaped, radiopaque lesions in 94 (4.04%) cases. There was 38 (1.4%) lesions present in maxilla. These included:

• 19 (0.72%) associated with the apex of the roots of tooth. Nine were situated in the anterior region and 10 in posterior region.
• 19 (0.72%) were in other locations (3 in anterior region 16 in posterior region).
  There were 56 (2.1%) lesions identified in the mandible,
• 4 (0.1%) of them were associated with the apex of the root. Two in the anterior region and 2 in posterior region.
• 52 (2%) were in other locations. Seven were in the anterior region, while 45 in the posterior region).

Figure 3: OPG showing a radio-opacity in posterior mandible

Radiolucencies:
Radiolucent lesions were more prevalent than radiopaque ones. A total of 308 (12%) radiolucencies were identified. Seventy-six (3%) of the total were present in maxilla, while 202 (7.7%) were in the mandible. In the maxilla:

• 63 (2.4%) associated with the apex of the root. Twenty- three (0.8%) of these were in anterior jaw, 40 (1.5%) were in the posterior region. Thirteen (0.5%) were in other locations, 3 located anteriorly and 10 posteriorly.
  Two hundred and thirty-two (8.8%) were found in the mandible.
• 189 (7.2%) were associated with the apex of the tooth, 45 in the anterior region while 144 in the posterior region.
• There were 43 (1.6%) lesions identified in other locations with 8 (0.3%) of them located anteriorly and 35 (1.3%) posteriorly.

Table 1: Distribution of maxillary and mandibular radiolucencies and radiopacities

Fractures: Fractures were noted on 17 (0.6%) OPGs in the mandible and 3 (0.1%) in the maxilla.

Table 2: Summary of results

DISCUSSION

Prior studies have shown variations in sizes and shapes of condyles, sinuses, styloid processes, IAC and mental foramen between populations.4,5,7-9,11-13 Since limited data was available from Pakistan, this study was performed to document the anomalies and pathologies noted on OPGs taken for routine dental care in a single institution. We included entities like sinus dilatation, styloid process elongation, cyst, tumors and fractures of the jaws. This was done by analyzing the OPG images and evaluating the maxillary sinus, condyle of mandible, styloid process, alveolar process, inferior alveolar canal and jaws individually and making record of each radiologic defect.
While OPGs can be used to recognize some maxillary sinus pathologies; such as cysts, pseudo cysts, fractures and others, overlapping structures make definitive assessment difficult, thus favoring reliance on other radiographic techniques.14,15 A study from Riyadh estimated the prevalence of maxillary sinus abnormalities at 39.4%.16 A similar study performed on the Mumbai population but using cone beam computed tomography (CBCT) found the prevalence of maxillary sinus abnormalities to be 59.7%.17 Our study estimated anomalies and abnormalities of the maxillary sinus at 64%. Like the Indian studies, we can expect this number to increase if more precise imaging, like CBCT is used. Sinus pneumatization can be seen in 40-78.7% of populations according to prior studies.16-19 The variations can be attributed to geographical differences.
Nasal fractures can be quite common. They account for 58.6% of facial fractures, and 40% of all bone fractures.20 This is most likely because of the prominent location of bone. In our estimate we only noted nasal fractures in 0.1% cases. This low estimate is probably a consequence of acquiring data from routine dental clinics of a single institute. Data from a tertiary healthcare center may yield different results. Deviated nasal septum is also a common finding in OPGs; severe cases can cause difficulty in breathing. We noted a deviated septum in 7.5% of the OPGs. Styloid complex consists of styloid process, styloid ligament and stylomandibular ligaments. Elongation of the styloid process can be appreciated on an OPG.21 We noted elongations in 12.1% of our OPGs. Our results are much lower than the reports from Brazil (44%), Saudi Arabia (44%) and Greece (27%).22-24 We have attributed this to geographical differences. While elongation of the styloid process is usually asymptomatic, it is linked with Eagle’s syndrome.21 Due to the absence of clinical information for our OPGs, we were unable to determine how many of our patients were symptomatic.
OPGs are of limited value when evaluating temporomandibular joint (TMJ) disorders.25,26 These radiographs are primarily used to assess asymmetries, extensive erosion, tumors and fractures.19 Our OPGs showed displacement of the condyle in about 19% of cases. This included both unilateral and bilateral displacements. Again, due to the absence of clinical information, we were unable to make a definitive assessment of TMJ disorders.
Radiolucencies and radiopacities in the jaw can be odontogenic or non-odontogenic. Periapical radiolucencies are a frequent finding on OPGs. We noted them in 9.7% of our sample. A similar study from England estimated the prevalence of periradicular radiolucencies at 6.8%.27 Other radiolucencies and radiopacities were also noted. Absence of clinical information makes interpretation of this data slightly difficult. A study on the Iranian populations has documented radio-opacities in 2.84% of their sample.28 Alveolar bone levels are important for implants placement, denture prosthesis placement, orthodontic treatment plan, evaluating periodontal health. Alveolar bone loss was frequent in our investigation. About 39% of our OPGs showed some degree of alveolar bone loss. Our results are corroborated by a Chinese study that showed alveolar bone loss rates at 39.2%.29 In other studies, bone loss in about 50% of the sample has also been reported.30 Despite this thorough evaluation of OPGs, our study has its limitations. Absence of clinical information made evaluation of our results difficult. While we tried our best to ensure inclusion of clear images, contrast level of our software could also have influenced our results. We were also unable to account for any magnification errors. For future studies we recommend inclusion of sample from multiple cities across Pakistan and from all types of healthcare facilities; clinics and hospitals.

CONCLUSION

1. Our results were somewhat unique when compared with studies from other geographical locations.
2. We established baseline statistics about the common anomalies and abnormalities noted in dental radiographs in Pakistan.
3. We believe that this knowledge will help Pakistani dentists familiarize themselves with common anomalies so they can identify abnormalities and provide appropriate patient care.

CONFLICT OF INTEREST

None to declare

REFERENCES

1. Vaseemuddin S. Incidental findings on panoramic radiograph: A clinical study. J Adv Med Dent Sci. 2016;4:223-26.
2. Altug HA, Ozkan A. Diagnostic imaging in oral and maxillofacial pathology. Croatia:Intech Europe. 2011;216:26.
3. Magat G, Ozcan S. Evaluation of styloid process morphology and calcification types in both genders with different ages and dental status. J Istanb Univ Fac Dent. 2017;51:29-36. https://doi.org/10.17096/jiufd.35768
4. Natsis K, Repousi E, Noussios G, Papathanasiou E, Apostolidis S, Piagkou M. The styloid process in a Greek population: An anatomical study with clinical implications. Anat Sci Int. 2014;90:67-74. https://doi.org/10.1007/s12565-014-0232-3
5. Watanabe PC, Dias FC I, JP,, Monteiro SA PF, de Paula FJ TR. Elongated styloid process and atheroma in panoramic radiography and its relationship with systemic osteoporosis and osteopenia. Osteopros
   Int. 2010;21:831-36. https://doi.org/10.1007/s00198-009-1022-y
6. Liu T, Xia B, Gu Z. Inferior alveolar canal course: a radiographic study. Clin Oral Implants Res. 2009;20:1212-18. https://doi.org/10.1111/j.1600-0501.2009.01736.x
7. Sahithi D, Reddy S, Divya Teja DV, Koneru J, Sai Praveen KN, Sruthi R. Reveal the concealed – Morphological variations of the coronoid process, condyle and sigmoid notch in personal identification.
   Egyptian J Forensic Sci. 2016;6:108-13. https://doi.org/10.1016/j.ejfs.2015.11.003
8. Yalcin ED, Ararat E. Cone-beam computed tomography study of mandibular condylar morphology. J Craniofac Surg. 2019;30:2621-24. https://doi.org/10.1097/SCS.0000000000005699
9. Alrahabi M, Zafar MS. Anatomical variations of mental foramen:A retrospective cross-sectional study. Int J Morpho. 2018;36:1124-29. https://doi.org/10.4067/S0717-95022018000301124
10. Alok A, Singh ID, Panat SR, Singh S, Kishore M, Jha A. Position and symmetry of mental foramen: A radiographic study in Bareilly population. Journal of Indian Academy of Oral Medicine and Radiology.
    2017;29:16-9. https://doi.org/10.4103/jiaomr.JIAOMR_69_16
11. Bakhsh A, Abed H, Hazzazi L, Alzebiani N, Nazer F, Yamany I, et al. Anatomical Variations and Biological Effects of Mental Foramen Position in Population of Saudi Arabia. Dentistry. 2016;6:373. https://doi.org/10.4172/2161-1122.1000373
12. Shahidi S, Zamiri B, Momeni Danaei S, Salehi S, Hamedani S. Evaluation of Anatomic Variations in Maxillary Sinus with the Aid of Cone Beam Computed Tomography (CBCT) in a Population in South of Iran. J Dent (Shiraz). 2016;17:7-15.
13. Selcuk A, Ozcan KM, Akdogan O, Bilal N, Dere H. Variations of maxillary sinus and accompanying anatomical and pathological structures. J Craniofac Surg. 2008;19:159-64. https://doi.org/10.1097/scs.0b013e3181577b01
14. White SC, Pharoah MJ. Oral radiology : principles and interpretation. 6th ed. ed. United States: St. Louis, Mo. : Mosby Elsevier, c2009.
15. Constantine S, Clark B, Kiermeier A, Anderson PP. Panoramic radiography is of limited value in the evaluation of maxillary sinus disease. Oral Surg Oral Med Oral Pathol Oral Radiol. 2019;127:237-
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16. Alqahtani S, Alsheraimi A, Alshareef A, Alsaban R, Alqahtani A, Almgran M, et al. Maxillary Sinus Pneumatization Following Extractions in Riyadh, Saudi Arabia: A Cross-sectional Study. Cureus. 2020;12:e6611-e. https://doi.org/10.7759/cureus.6611
17. Raghav M, Karjodkar FR, Sontakke S, Sansare K. Prevalence of incidental maxillary sinus pathologies in dental patients on cone-beam computed tomographic images. 2014;5:361-65. https://doi.org/10.4103/0976-237X.137949
18. Tolstunov L, Thai D, Arellano L. Implant-guided volumetric analysis of edentulous maxillary bone with cone-beam computerized tomography scan. Maxillary sinus pneumatization classification. J Oral Implantol. 2012;38:377-90. https://doi.org/10.1563/AAID-JOI-D-11-00212
19. Elsayed SA, Alolayan AB, Alahmadi A, Kassim S. Revisited maxillary sinus pneumatization narrative of observation in Al-Madinah Al-Munawwarah, Saudi Arabia: A retrospective cross-sectional study.
    Saudi Dent J. 2019;31:212-218. https://doi.org/10.1016/j.sdentj.2018.11.002
20. Kucik CJ, Clenney TL, Phelan J. Management of acute nasal fractures. Am Fam Physician. 2004;70:1315-20.
21. Gokce C, Sisman Y, Ertas ET, Akgunlu F, Ozturk A. Prevalence of styloid process elongation on panoramic radiography in the Turkey population from cappadocia region. Eur J Dent. 2008;2:18-22.
    https://doi.org/10.1055/s-0039-1697348
22. Vieira EM, Guedes OA, Morais SD, Musis CR, Albuquerque PA, Borges ÁH. Prevalence of Elongated Styloid Process in a Central Brazilian Population. J Clin Diagn Res. 2015;9:ZC90-2. https://doi.org/10.7860/JCDR/2015/14599.6567
23. AlZarea BK. Prevalence and pattern of the elongated styloid process among geriatric patients in Saudi Arabia. Clin Interv Aging. 2017;12:611-17. https://doi.org/10.2147/CIA.S129818
24. Natsis, K., Repousi, E., Noussios, G. et al. The styloid process in a Greek population: an anatomical study with clinical implications. Anat Sci Int 2015;90:67-74. https://doi.org/10.1007/s12565-014-0232-3
25. Westesson PL. Reliability and validity of imaging diagnosis of temporomandibular joint disorder. Adv Dent Res. 1993;7:137-51. https://doi.org/10.1177/08959374930070020401
26. Crow HC, Parks E, Campbell JH, Stucki DS, Daggy J. The utility of panoramic radiography in temporomandibular joint assessment. Dentomaxillofac Radiol. 2005;34:91-5. https://doi.org/10.1259/dmfr/24863557
27. Richardson PS. Panoramic radiographic screening: a risk-benefit analysis. Prim Dent Care. 1997;4:71-7.
28. Naser AZ, Roshanzamir N. Prevalence of idiopathic osteosclerosis in an Iranian population. Indian J Dent Res. 2016;27:544-46. https://doi.org/10.4103/0970-9290.195679

1. Final year student, Riphah International University, Islamabad.
2. Final year student, Riphah International University, Islamabad.
3. Final year student, Riphah International University, Islamabad.
4. Demonstrator, Department of Oral Medicine, Riphah International University, Islamabad.
5. Assistant Professor, Department of Oral Diagnosis and Medicine, Riphah International University, Islamabad.
Corresponding author: “Dr. Amber Kiyani” < akiyani@gmail.com >

Samra Asif

Hassaan Bin Babar

Fatima Kamal

Kanwal Sohail

Amber Kiyani              BDS, M.Phil

OBJECTIVES: Orthopantomogram (OPG) is a dental radiograph that captures the maxillofacial region in a single image for quick assessment of the dental arches and their surrounding structures. It can be used for treatment planning and analysis of jaw-related pathologies. Prior studies have demonstrated geographical variations in radiographic anomalies and pathologies, our purpose was to establish baseline statistics for the Pakistani population, so the Pakistani dentists are able to distinguish between anomalies and pathologies and provide appropriate care when needed.
METHODOLOGY: A cross-sectional study design was used to analyze de-identified 2411 OPGs taken for routine dental care at the dental clinics of Riphah International University. These were broadly classified according to site. Data was documented on SPSS version 22 and presented as frequencies.
RESULTS: From a total of 2,411 OPGs, 2326 met the inclusion criteria. The mean age of the patients was 29.06±17.99 years. Our findings included pneumatization of the maxillary sinus in 9.8%, pathological findings in the sinus in 3.9%, deflected nasal septum in 7.5%, alveolar bone loss in 32.7%, elongated styloid process in 12.1%, pathological finding associated with maxillary bone in 1.4% and mandibular bone in 2.1%.
CONCLUSIONS: Our results were somewhat unique when compared with studies from other geographical locations. We established baseline statistics about the common anomalies and abnormalities noted in dental radiographs for the Pakistani population.
KEY WORDS: Orthopantomogram, anomalies, mandible, maxilla
HOW TO CITE: Asif S, Babar HB, Kamal F, Sohail K, Kiyani A. Prevalence of radiographic anomalies and abnormalities on panoramic films in the Pakistani population. J Pak Dent Assoc 2021;30(2):124-129.
DOI: https://doi.org/10.25301/JPDA.302.124
Received: 30 June 2020, Accepted: 01 January 2021
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Sana Viqar                         BDS

Sadia Rizwan                    BDS, FCPS

Syed Shah Faisal              BDS, FCPS

Syed Sheeraz Hussain     BDS, DCPS (HCSM), MCPS, FCPS

INTRODUCTION

Impacted tooth is defined as “a tooth which is completely or partially unerupted and is positioned against another tooth, bone or soft tissue so that its further eruption is unlikely, within the expected time”.1 When teeth fail to develop or erupt in their correct functional location, they become impacted.2
Studies have reported third molar as one of the most commonly impacted tooth accounting for 98% of tooth impactions.3,4 Mandibular third molar has more tendency for impaction as compared to maxilla.5 It was noted that 3 to 4 years of ageis the time when crypt formation ofthird molar begins, while calcification starts at the age of 7 to 10 years.6 Third molar eruption time varies, starting from 16 years until 18-20 years or even later in life depending on dental and bony changes among different individuals.7
Because this molar is the last tooth in the mouth to erupt, one hypothesis has been proposed that impaction of this tooth is because of lack of space in retromolar area which occurs due to reduction in human jaw size with evolution.8,9 Regardless of adequate growth, third molar impaction can occur if dentition does not move forward due of lack of interproximal wear (attributable to diet changes in the modern population). In a study by Gooris et al. (1990), it was noted that after second molar extraction, third molars were rarely observed impacted, suggestive of an increase in the eruption space. Likewise Kim et al. (2003) suggested that extraction of premolar as a part of orthodontic treatment resulted in decreased frequency of third molar impaction. Such studies show that third molar impaction occurs mainly due to lack of eruption space.10

Inadequate space at retromolar area is also associated with the direction of growth. The direction of growth of facial skeleton determines the vertical facial type. In a ”mesiofacial” pattern, facial skeleton growth is forward and downward with a relative harmony between two directions. In “brachyfacial” pattern, there is anticlockwise rotation of mandible resulting in wide face and reduced anterior facial height. In “dolichofacial” pattern, clockwise rotation of mandible results in long face and increased anterior facial height.10

Broadbent believed that third molar impaction occurred when mandible failed to grow till its full potential.11 Bjork emphasized on role of direction of growth inimpaction; reduced growth with a downward direction rather than forward being associated with impaction of mandibular third molar.6 In a study by Legovic et al., no significant association was found in mandibular third molar eruption status and the type of facial growth.12 As studies show controversial results, this provides a strong rationale to conduct this research in Pakistani population, as our population differs genetically and geographically. If results of this study show dominance of mandibular third molar impactions in patients with downward growth pattern, the possible role of skeletal vertical growth in impaction of third molar could be identified and it may become possible to predict third molar impaction ahead of time in vertically growing patients. Thus, the objective of this study is to determine the frequency of mandibular third molar impaction in different vertical skeletal types of faces.

METHODOLOGY

The study was conducted at Orthodontics department, Karachi Medical and Dental College, Karachi, Pakistan. Duration of study was 6 months after getting approval from Ethical Review Comittee. Study design was cross-sectional. By using WHO sample size calculator, by taking statistics for third molar impaction as 33.33%2 , margin of error as 10% and 95% confidence interval; the sample size was calculated to be 86. Stratified sampling was used. Sample consisted of 90 patients. Verbal informed consent was taken from the patients and all data was collected by a single researcher. The inclusion criteria was patients of age range between 18-30 years with good quality pre-treatment OPGs and lateral cephalometric x-rays available, having mesiofacial, brachyfacial and dolichofacial skeletal pattern and all permanent dentition present including third molars. The exclusion criteria was history of orthodontic treatment or orthognathic surgery, craniofacial anomalies/syndromes, any tooth anomaly of number, size, form and position and retained deciduous teeth. The skeletal type of face was determined on lateral cephalogramby measuring facial axis angle and mandibular plane angle. Landmarks identified on the lateral cephalogram included Nasion(Na), Basion(Ba), Gnathion(Gn), Porion(Po), Orbitale(Or), Menton(Me) Pterygomaxillary fissure(Ptm) and Antegonion(Ag). Facial axis was measured as the posterior angle formed by the lines Basion-Nasion and Pterygomaxillary fissure-Gnathion. Mandibular plane angle was measured as angle formed between Frankfort horizontal plane(Porion-Orbitale) and Mandibular plane (Antegonion-Menton) on lateral cephalogram. Patients were divided into three categories according to vertical facial types;I – Mesiofacial (Facial axis angle 90±3 and mandibular plane angle 26±3). II – Brachyfacial (Facial axis angle >93 and mandibular plane angle <23). III – Dolichofacial (Facial axis angle <87 and mandibular plane angle >26).

Mandibular third molar impaction status was assessed on OPG x-ray. The level of impaction of third molar was categorized into three groups on basis of Pell and Gregory classification:

1. Level A defined as “the highest part of the mandibular third molar was on the same level or below the occlusal plane of the adjacent second molar”.7
2. Level B defined as”the highest part of the mandibular third molar was below the occlusal plane but above the cervical line of the second molar”.7
3. Level C defined as”the highest part of the mandibular third molar was beneath the cervical line of the second molar”.7

Three groups were established on the basis of third molar eruption status; A – Erupted third molar (Level A of P&G), B – Partially impacted third molar (Level B of P&G),C – Complete impaction (Level C of P&G).

DATA ANALYSIS

Analysis of collected data was done using SPSS version 23.0. The subjects were divided into three groups and their presence measured in frequency and percentage. The frequency of third molar impaction in different vertical skeletal types of faces was measured as percentage. The subjects were then also categorized according to gender and frequency of third molar impaction was found for males and females. RESULTS A total of 90 patients were included in this study who were divided into three groups depending on skeletal vertical facial type – 30 mesiofacial, 30 brachyfacial, 30 dolichofacial. Each facial group comprised of 33.3% of total subjects in this study. All patients were evaluated radiographically. The distribution of mandibular third molar impaction status in different vertical facial types is shown in Table 1.

Table 1: Distribution of third molar impaction in different facial types

Results showed that complete impaction of mandibular third molar was most common among dolichofacial patients. Among 29 completely impacted mandibular third molars, 14 belong to dolichofacial, 9 belonged to mesiofacial and 6 belonged to brachyfacial group. Erupted third molars were mostly found in brachyfacial patients. Among 32 erupted mandibular third molars, 16 belong to brachyfacial, 11 belonged to mesiofacial and 5 belonged to dolichofacial group. There was no significant difference for partially impacted third molars among the 3 groups of facial types. Results show significant differences in frequency of third molar impaction among male and female patients, with their increased prevalence found in females as compared to males. The distribution of mandibular third molar impaction in different genders is shown in Table 2.

Table 2: Distribution of third molar impaction among different genders

DISCUSSION

Consideration of mandibular third molar status is important from orthodontic viewpoint as these teeth are considered to be responsible for crowding of lower anterior teeth, relapse in the lower anterior crowding after orthodontic treatment, interfering with uprighting of first and second molars, distalization of molars, caries, and pericoronitis.2 The complications of third molar impaction can be prevented with timely proper orthodontic treatment.13,14
In this study, the frequency of mandibular third molar impaction was found to be 64.4%. This is in consistence with the findings of Nanda and Sandhu and Kaur who noted 40%-68.9% of third molar impaction in South Indian population.15,16 However, results of this study differed from those observed by Obiechina et al., who found prevalence of third molar impaction to be 72.09% of the Nigerian population, and also Grover and Lorton who observed 96.5% of the third molar impaction.17,18 In addition, the frequency found in this study was significantly more than that of Scherstén et al. who observed 33%,Hattab et al. who
observed 28.2% and Ma’aita who found 40.5% of third molar impaction.19-21 Moreover, in this study the frequency of mandibular third molar impaction in males was found to be 56.4% and 70.6% in females. This is similar to findings of the majorityof authors that prevalence of third molar impaction is greater in females as compared to males.10 The similar rates of impaction among genders were found in the study by Dachi and Howell.22
In this study the sample was categorized according to the vertical skeletal malocclusion of patient. The mandibular plane angle indicates growth direction of mandible, with high values representing dolichofacial subjects and low values representing brachyfacial ones. Facial axis, whose value is determined by the shape and position of the mandible, indicates growth direction of the chin and is not susceptible to change by age. Thus, values above 90º point to forward growth (brachyfacial pattern).23 Therefore, mandibular rotation which ultimately determines the pattern of facial growthis a significant factor affecting the retromolar
space.7
Lack of retromolar space between distal of second molar and the ascending ramus mostly affects mandibular third molar causing failure of its eruption. Bjork et al. noted that patients in whom mandibular third molar was impacted, 90% were found to have decreased space in the retromolar area.24 Mandibular growth direction plays a significant role in third molar eruption. Third molar eruption can be impeded
if the anterior aspect of mandibular ramus has reduced remodeling resorption. In patients with anterior growth rotation, compensation for this reduced resorption occurs by more forward eruption of third molars during functional phase.7
It was also demonstrated that three skeletal factors contribute to this diminished space; 1) Short mandibular length 2) Vertical direction of condylar growth 3) Backward directed eruption of the dentition.10 The most important factor was the vertically directed condyle growth, found predominantly in dolichofacial subjects.10 Capelli claims that third molars are found to become impacted more frequently in mandibles with a vertical growth pattern.25 A long ramus with short mandibular length are thought to be indicative of the impaction of mandibular third molar.26 Results of this study showed that majority (48.3%) of all
completely impacted teeth belonged to patients with dolichofacial pattern.
The short mandibular length which is considered second most important factor, predisposed to impaction of third molar. Conversely, according to Kaplan and Dierkes, there was no significant difference in mandibular lengthsof patients with erupted and impacted third molars.24 Eroz et al. and Capelli found in their studies that patients with dolichofacial facial growth pattern had shorter mandibular lengths,
consistently supporting the hypothesisof greater chances of third molar impaction in patients with dolichofacial pattern (26,27). These findings are in consistence with results of this study which showed that among all erupted third molars, 50% belonged to brachyfacial group, 34.4% belonged to mesiofacial group and 15.6% belonged to dolichofacial group. Nanda et al, noted that growth period varied from one facial form to another. It was shown that compared to dolichofacial patients, brachyfacial patients had a longer period of facial growth.28 This extended growth period accounts for greater resorption of the anterior border of ramus resulting in an increase in retromolar space. According to Breik et al., the prevalence of mandibular third molar impaction was almost two times less in short face patients as compared to long face patients.27 These finding are in consistence with the results of our study. However, in a study by Sogra et al. 2014, no statistical significant difference was found among the frequency of mandibular third molar impaction in different facial growth patterns. 7
This study showed no significant difference in impaction and eruption rates of third molar in mesiofacial group. This could be due to limitations in the study including number of subjects and the sample type. Patients coming for orthodontic treatment usually present with dentoskeletal malocclusions and thus, they have higher chances of impaction of mandibular third molar.10 Another limitation in this study related to sample could be the age limit. The age range of patients involved in this was 18 to 30 years. Growth of mandible is normally completed by16-17 years and development of third molar is usually at its final stage
at 18 years. Recent literature has shown that vertically positioned third molars may undergo progressive uprighting up to the age of 25 resulting in their complete eruption in the oral cavity.4
A tooth impacted at 18 years of age has approximately 30 to 50% chance of complete eruption, except horizontal impactions.29 In a study by Kruger et al., third molars which were impacted at 19 years showed full eruption by 26 years of age.30 Venta et al. showed that similar changes can be seen up to 32 years of age.31 Therefore, the impaction status of third molar described in this study is the one recorded in the pretreatment radiograph and may not be the probable final status. Further avenues for research may be to carry out a longitudinal study and assess the changes in third molar status with time.19 It is suggested that future epidemiological surveys with larger sample sizes and diverse target populations should be carried out in order to test the validity of findings of our study.

CONCLUSIONS

1. The majority of erupted mandibular third molars were found in patients with brachyfacial skeletal pattern due to forward direction of mandibular growth contributing to greater resorption at anterior border of ramus and additional space required for third molar eruption.
2. Highest occurrence of completely impacted mandibular third molars was found in patients with dolichofacial skeletal pattern.
3. Among genders, females were found to have higher frequency of mandibular third molar impaction in comparison to males.
4. From the findings of this study, author suggests clinicians to investigate status of mandibular third molar especially in female patients with dolichofacial pattern to prevent any complications associated with impaction of these teeth. As these patients are more prone to complete impaction of mandibular third molar, author recommends performing further research on this at larger scale so that predictions can be well established.

CONFLICT OF INTEREST

None to declare

REFERENCES

1. Santosh P. Impacted mandibular third molars: Review of literature and a proposal of a combined clinical and radiological classification. Annals Medi Health Sci Res. 2015;5:229-34. https://doi.org/10.4103/2141-9248.160177
2. Jain S, Debbarma S, Prasad S. Prevalence of impacted third molars among orthodontic patients in different malocclusions. Indian J Dent Res. 2019;30:238. https://doi.org/10.4103/ijdr.IJDR_62_17
3. Jakovljevic A, Lazic E, Soldatovic I, Nedeljkovic N, Andric M. Radiographic assessment of lower third molar eruption in different anteroposterior skeletal patterns and age-related groups. The Angle Orthodontist. 2015;85:577-84. https://doi.org/10.2319/062714-463.1
4. Kumar VR, Yadav P, Kahsu E, Girkar F, Chakraborty R. Prevalence and Pattern of Mandibular Third Molar Impaction in Eritrean Population: A Retrospective Study. J Contemp Dent Pract. 2017;18:100. https://doi.org/10.5005/jp-journals-10024-1998
5. Demirel O, Akbulut A. Evaluation of the relationship between gonial angle and impacted mandibular third molar teeth. Anat Sci Int. 2020;95:134-42. https://doi.org/10.1007/s12565-019-00507-0
6. Sapkota MR, Bhatta S, Shrestha S, Shrestha RM. Position of impacted mandibular third molar in different skeletal facial types. Orthod J Nepal. 2017;7:15-9. https://doi.org/10.3126/ojn.v7i2.20154
7. Yassaei S, Wlia F, Nik Z. Pattern of third molar impaction; correlation with malocclusion and facial growth. J Oral Health and Dental Management. 2014;13:1096-9.
8. Carter K. The evolution of third molar agenesis and impaction 2016.
9. Juodzbalys G, Daugela P. Mandibular third molar impaction: review of literature and a proposal of a classification. J Oral & Maxillofac Res. 2013;4. https://doi.org/10.5037/jomr.2013.4201
10. Bashir S, Rasool G, Afzal F, Hassan N. Incidence of mandibular 3rd molar impactions in different facial types of orthodontic patients seen at Khyber College of Dentistry. Pak Oral Dent J. 2016;36.
11. Broadbent BH. The influence of the third molars on the alignment of the teeth. Am J Orthod Oral Surg. 1943;29:312-30. https://doi.org/10.1016/S0096-6347(43)90384-9
12. Legovic M, Legovic I, Brumini G, VanDura I, Cabov T, Ovesnik M, et al. Correlation between the pattern of facial growth and the position of the mandibular third molar. J Oral Maxillofac Surg. 2008;66:1218-24. https://doi.org/10.1016/j.joms.2007.12.013
13. Abu Alhaija E, AlBhairan H, AlKhateeb S. Mandibular third molar space in different antero-posterior skeletal patterns. The European J Orthod. 2011;33:570-6. https://doi.org/10.1093/ejo/cjq125
14. Farzanegan F, Goya A. Evaluation of mandibular third molar positions in various vertical skeletal malocclusions. J Dent Mater Tech. 2012;1:58-62.
15. Nanda RS. Agenesis of the third molar in man. Am J Orthodontics. 1954;40:698-706. https://doi.org/10.1016/0002-9416(54)90058-5
16. Sandhu S, Kaur T. Radiographic evaluation of the status of third molars in the Asian-Indian students. J Oral Maxillofacl Surg. 2005;63:640-5. https://doi.org/10.1016/j.joms.2004.12.014
17. Obiechina AE, Arotiba JT, Fasola AO. Third molar impaction: evaluation of the symptoms and pattern of impaction of mandibular third molar teeth in Nigerians. Tropical Dent J. 2001:22-5.
18. Grover PS, Lorton L. The incidence of unerupted permanent teeth and related clinical cases. Oral Surg, Oral Medi, Oral Pathol. 1985;59:420-25. https://doi.org/10.1016/0030-4220(85)90070-2
19. Hattab FN, Ma’amon AR, Fahmy MS. Impaction status of third molars in Jordanian students. Oral Surg, Oral Medi, Oral Pathol, Oral Radiol, Endodont. 1995;79:24-9. https://doi.org/10.1016/S1079-2104(05)80068-X
20. Schersten E, Lysell L, Rohlin M. Prevalence of impacted third molars in dental students. Swedish Dent J. 1989;13(1-2):7-13.
21. Ma’aita JK. Impacted third molars and associated pathology in Jordanian patients. Saudi Dent J. 2000;12:16-9.
22. Keris EY, Bozkaya S, Öztürk M, Güngör K. Prevalence and characteristics of impacted permanent molars in a Turkish subpopulation. J Oral Maxillofac Radiol. 2016;4:45. https://doi.org/10.4103/2321-3841.196345
23. de Diego RG, Montero J, López-Valverde N, de Nieves JI, PradosFrutos J-C, López-Valverde A. Epidemiological survey on third molar agenesis and facial pattern among adolescents requiring orthodontic treatment. J clinical and Experimental Dentistry. 2017;9:e1088.
24. Shokri A, Mahmoudzadeh M, Baharvand M, Mortazavi H, Faradmal J, Khajeh S, et al. Position of impacted mandibular third molar in different skeletal facial types: First radiographic evaluation in a group of Iranian patients. Imaging Sci in Dent. 2014;44:61-5. https://doi.org/10.5624/isd.2014.44.1.61
25. Capelli Jr J. Mandibular growth and third molar impaction in extraction cases. The Angle Orthodontist. 1991;61:223-29.
26. Tassoker M, Kok H, Sener S. Is there a possible association between skeletal face types and third molar impaction? A retrospective radiographic study. Medi Principles Pract. 2019;28:70-4. https://doi.org/10.1159/000495005
27. Breik O, Grubor D. The incidence of mandibular third molar impactions in different skeletal face types. Australian Dent J. 2008;53:320-4. https://doi.org/10.1111/j.1834-7819.2008.00073.x
28. Nanda SK. Patterns of vertical growth in the face. Am J Orthod Dentofac Orthoped. 1988;93:103-16. https://doi.org/10.1016/0889-5406(88)90287-9
29. Ryalat S, AlRyalat SA, Kassob Z, Hassona Y, Al-Shayyab MH, Sawair F. Impaction of lower third molars and their association with age: radiological perspectives. BMC oral health. 2018;18:58. https://doi.org/10.1186/s12903-018-0519-1
30. Kruger E, Thomson WM, Konthasinghe P. Third molar outcomes from age 18 to 26: findings from a population-based New Zealand longitudinal study. Oral Surg, Oral Medi, Oral Pathol, Oral Radiol, and Endod. 2001;92:150-55. https://doi.org/10.1067/moe.2001.115461
31. Ventä I, Turtola L, Ylipaavalniemi P. Radiographic follow-up of impacted third molars from age 20 to 32 years. International J Oral Maxillofac Surg. 2001;30:54-7. https://doi.org/10.1054/ijom.2000.0002

1. Postgraduate FCPS Resident, Department of Orthodontics, Karachi Medical and Dental College, Karachi.
2. Assistant Professor, Department of Orthodontics, Dr. Ishrat-ul-Ibad Khan Institute of Oral Health Sciences, Karachi.
3. Professor, Department of Orthodontics, Karachi Medical and Dental College, Karachi.
4. Professor and Principal, Head of Department Orthodontics, Karachi Medical and Dental College, Karachi.
Corresponding author: “Dr. Sana Viqar” < sanaviqar@yahoo.com >

Sana Viqar                         BDS

Sadia Rizwan                    BDS, FCPS

Syed Shah Faisal              BDS, FCPS

Syed Sheeraz Hussain     BDS, DCPS (HCSM), MCPS, FCPS

OBJECTIVE: To determine the frequency of mandibular third molar impaction in different vertical skeletal facial types.
METHODOLOG: Data was collected using pre-treatment records including orthodontic files, pre-treatment lateral cephalograms and OPGs of 90 orthodontic patients. Patients from both genders were included. The age group of selected patients was 18-30 years. Vertical skeletal malocclusion was measured using facial angle and mandibular plane angle on cephalogram to group the subjects into Mesiofacial, Brachyfacial and Dolichofacial patients. Third molar eruption status was assessed using OPG.
RESULTS: Results showed that erupted third molars were mostly found in brachyfacial patients. Among 32 erupted mandibular third molars, 16 belong to brachyfacial, 11 belonged to mesiofacial and 5 belonged to dolichofacial group. Complete impaction of mandibular third molar was most common among dolichofacial patients. Among 29 completely impacted mandibular third molars, 14 belong to dolichofacial, 9 belonged to mesiofacial and 6 belonged to brachyfacial group. No significant difference was found for partially impacted third molars among the three groups of facial types. There was higher prevalence of mandibular third molar impaction in females as compared to males.
CONCLUSION: Frequency of third molar impaction was found to be highest in dolichofacial patients and lowest in brachyfacial patients due to forward direction of mandibular growth contributing to greater resorption of the anterior border of ramus and the additional space required for third molar eruption.
HOW TO CITE: Viqar S, Rizwan S, Faisal SS, Hussain SS. The frequency of mandibular third molar impaction in different types of vertical skeletal faces. J Pak Dent Assoc 2021;30(2):118-123.
DOI: https://doi.org/10.25301/JPDA.302.118
Received: 20 November 2020, Accepted: 12 February 2021
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