Alginate Impression

Myanmar Dental Journal - Vol. 22, No.
1, January 2015
Myanmar
Dental
Journal
Vol.22, No.1
January 2015
Myanmar Dental Journal - Vol. 22, No. 1, January 2015
Content
Editorial...........................................................................................................................................................3
Review Articles
v
Impact of periodontal diseases on Systemic Health..........................................................................4
Original Research Articles

v
Role Of Human Papillomavirus (HPV) And Its Detection In Potentially
Malignant Disorders And Oral Squamous Cell Carcinomas.............................................................9
Epidemiological and Clinico-pathological study of 120 cases .......................................................13
of Oral Cancers in Myanmar 2012
A new peripheral tracing material for mandibular complete denture impression............................17
Effect of mixing methods and disinfection on dimensional accuracy of ........................................21
alginate Impression
An in vitro study on coronal microleakage of endodontic acess cavity using ...............................27
single seal and double seal techniques
A comparative study on the dimensional accuracy of two types of ................................................33
elastomeric impression materials
In vitro study of margical fit of ceramage crown related to different margin Designs....................41
Case Report
v
A case report of Superior Ankyloglossia.........................................................................................48
Editorial
Fight against Oral Cancer

Oral cancer is the sixth most common cancer globally and majority of cases occur in South East Asia. While
tobacco smoking and betel quid chewing are major risk factors, the connection with HPV 16/18 (human
papilloma virus, type 16/18), which are viral and sexually transmitted, virus has to be considered seriously
especially among the young individuals without any tobacco habits. Historically, the death rate associated
with this cancer is particularly high, not because it is hard to discover or diagnose, but due to the cancer being
routinely discovered at late stage. Moreover, it is a disease that has limited public awareness and number of
cases increasing each year in developing countries.
The only hope for saving lives is with professional involvement and public awareness. As for the professional
involvement, the dental community is the first line of defense against oral cancer, through the process of early
detection. Including both generalist and specialists, there are nearly 3000 dentists in Myanmar. Just doing
opportunistic cancer screenings of the existing patient population visit to dental office can catch oral cancer in
its early stage. The good news is that if it is caught early enough then the chances of survival are substantially
increased.
Oral Medicine and Oral Pathology Society are looking forward to develop Oral cancer Foundation in our
country in future and collaborate with International Oral Cancer Foundations. Our goals are not only to initiate
an effort within the dental community to screen all the dental patients and but also intended to drive public
awareness of oral cancer. Education of the public regarding the risk factors, recognition of the early signs and
symptoms are primary responsibilities of dental community.
Encouraging patients to perform self-diagnosis such as looking for ulcers that do not heal within three weeks,
red or white patches in the mouth and any unusual lumps or swelling can also help towards early detection.
We would like to invite all Dental professionals to participate and be as a partner with us by helping to raise
awareness of oral cancer and make a positive difference to thousands of lives.
Professor Swe Swe Win

Vice President, Myanmar Dental Association and
Oral Medicine and Pathology Society
Chairman, Academic Committee
References:
1. http://oralcancerfoundation.org
2.
www.mouth cancer.com
Review Article
Impact of periodontal diseases on

Systemic Health
Shrinidhi1, Usha Chikkaiah2, Shivakumar1
1
Department of Periodontics, Sharavathi Dental College and Hospital, Shivamogga, India
Department of Oral Medicine & Radiology, Sharavathi Dental College and Hospital, Shivamogga, India
Abstract:
Systemic Health has been accepted by the medical

fraternity for quite some time1. The impacts systemic
diseases have on the Oral tissues are well known and
often it is the Oral Cavity which presents with the
early signs of a disease2. However is the converse
true? Do the dental diseases have any effect on the
etiology or progression of the Systemic diseases?2
The answer is a much awaited one .The role of
oral diseases in eliciting a systemic response, in an
otherwise healthy individual has often been the topic
of debate in the field of current scientific research.
After the dawn of Evidence Based Clinical Practice,
it is absolutely essential to shed light on this aspect
of Periodontal Medicine, which will provide a clear
understanding of its implications on the general
health of the patient3.
A plethora of Systemic diseases have effect on Oral

health, showing their manifestations in various ways.
Diabetics suffering from multiple dental problems
or Tuberculosis winding its way to the gingiva are
but a few of such examples. However, do the oral
diseases exert any action on the general health of an
individual? This has been a matter of concern both
to the Medical and Dental Professionals for quite
some time. Recent studies have documented that
oral diseases are indeed risk factors for a variety of
multi organ diseases.
Periodontal diseases are the group of diseases
affecting the investing tissues of teeth. They have
affected mankind since ages and still continue to
haunt them leading to tooth mortality. A few of
Oral diseases, or Periodontal diseases in particular
create a chronic inflammatory state, wherein there
is a gradual rise of pro-inflammatory mediators.
Haematogenous spread of bacteria from oral
cavity into systemic circulation results in marked
changes in the systemic health. This risk factor
can be a magnifier or an initiator for Preterm labor,
Atherosclerosis, Coronary Heart Disease and Poor
Glycemic control in Diabetics.
Periodontal Disease:
Periodontium means structures surrounding the teeth
and they are the Gingiva, Periodontal ligament (a
soft collagenous tissue which attaches the root to the
bone), Cementum (a hard calcified covering on the
root), and Alveolar bone. Thus, Periodontal diseases
are a group of diseases which affect the integrity of
the teeth resulting in bone loss, tooth mobility and
tooth loss4.
The aim of this paper is to provide a birds eye-view

of Periodontal medicine for the Practicioner as it
has a profound influence on clinical practice in the
current times.
The gingival crevice forms an ideal niche for the

bacterial flora. The environment is oxygen depleted
one, where the anaerobic flora thrive and produce
toxins. Although the sulcus is continuously bathed
by the flow of the crevicular fluid, which tends
to flush out these microbes or kill them by their
antibacterial properties, the bacteria still evade them
by their virulence factors and tissue destroying
components like Lipopolysaccharide (LPS)4,5.These
Key words: Periodontal disease, Periodontal

medicine, Systemic health,
INTRODUCTION:
The old Saying Oral health is the Mirror of
4
products enter the systemic circulation through

a breach in the host defense and evoke a potent
inflammatory response. A continued inflammatory
response creates a chronic inflammatory state that
leads to a cascade of events in a distant site5.
field of research in Microbiology and immunology

have led to an extensive exchange of knowledge
between the dental and medical sciences, thereby
evoking a re-interest in the concept of Focal
infection4,5.
Focal Infection theory Revisited:
Effects of oral diseases on remote sites1,2:
The focal infection theory put forth in 1900s by

William Hunter, a British Physician, created a wave
amongst the practitioners, as it blamed the oral micro
organisms for a wide range of systemic diseases
.However, this fame was short-lived as multiple
extractions failed to produce the desired level of
therapeutic benefit. Recently, the expansions in the
Numerous cross-sectional and longitudinal studies

have confirmed that periodontal diseases (diseases
of investing tissues of teeth) may affect or influence
the progression of following conditions:
DIABETES MELLITUS:
or cheilosis6. Diabetes alters the oral ecoflora, with

a predominance of Capnocytophaga, Anaerobic
vibrios, and Actinomyces species. In addition,
there is a change in Collagen metabolism and
Polymorphopnuclear Leukocyte function, all of
which are detrimental to the health of periodontal
tissues as they make them more susceptible for
infections7.
The American diabetes Association has included

Periodontitis as one amongst the many known
complications of this complex metabolic disorder.
Recently, it has been termed as the 6th complication
of Diabetes (the other five being, Retinopathy,
Nephropathy, Neuropathy, Macro vascular disease
and Altered wound healing)6.
Recently, it has been suggested that Diabetes and

Periodontal disease share a two way relationship7.
Studies have shown that patients with severe
periodontal breakdown have poor glycemic control
because of increased insulin resistance and poor
penetration of glucose in to the cells. Moreover,
The effects of Diabetes Mellitus on oral tissues

have been well documented. It is known to magnify
periodontal disease, causing multiple abscesses,
bone loss, tooth mobility and also increase the
rate of dental caries. Moreover, the patients also
complain of xerostomia, mucosal drying, burning
5
patients who received periodontal therapy exhibited

a better control over their blood glucose levels. This
improved glycemic control could be attributed to
the resolution of chronic inflammatory state which
in turn reduced the insulin demand, increased the
insulin sensitivity and enhanced the penetration
of glucose in to the cells. This emphasizes the
importance of control over both these conditions to
achieve a good glycemic control7,8.
provided beneficial results. Many studies since,

have confirmed the association between Preterm
Low Birth Weight and Periodontal disease10.
EFFECTS ON THE CARDIOVASCULAR OR
CERBROVASULAR SYSTEMS:
The existence of a chronic inflammatory state
created by Periodontal infection pave the way for
development of Congestive Heart Disease (CHD).
Classic studies of Mattila and coworkers, with
exclusion of life style and other risk factors, have
drawn parallel between the periodontal disease and
severity of atheroma formation. It has been observed
that for patients with oral diseases, an overall risk
of 19%, and a 44% risk for persons below 65 years,
exists for developing CHD12.
PREGNANCY OUTCOME:
Pregnancy ushers in a myriad of changes in the
structure and composition of the Periodontal tissues9.
Changes in the hormonal levels in the first and third
trimester increase the susceptibility to infection.
Pregnancy associated gingivitis or at times tumor
like masses, often referred to as Pregnancy tumors
are not uncommon9.
There is an increase in the viscosity of blood and

WBC counts in Periodontitis. Again, elevated
levels of Von Willebrand factor and fibrinogen
levels promote thrombus formation or occlusion
of blood vessels, thereby precipitating myocardial
ischemia13. Also, the bacterial endotoxins seep
into the circulation from the oral site and elicit an
inflammatory response. The atherosclerotic changes
induced by the above factors, elicit narrowing of the
coronary arteries leading to myocardial ischemia13.
Another condition of serious concern or rather

of utmost clinical significance is Preterm labor or
premature rupture of membranes which lead to
low birth weight infants. Such infants suffer from
poor immunity, infections and other congenital or
developmental disorders9. There are ample risk
factors for the above, stress, smoking, alcohol,
diabetes, hypertension, genito-urinary tract infection,
to name a few. Bacterial vaginosis is a recognized risk
factor for Preterm labor10. The bacterial endotoxins
may either injure the tissues or stimulate the release
of Cytokines- Interleukin 1 &6, TNF-alpha and
Prostaglandins prematurely, thereby elevating the
levels of the pro-inflammatory mediators in the
amnion which predispose them to development of
preterm labor11. There is a significant correlation
between elevated levels of these mediators, fetal
death and growth retardation. An intriguing factor
is, some studies have isolated Fusobacterium
nucleatum, a common oral pathogenic microflora
in the amniotic fluid of women who had Preterm
labor, while this microbe is relatively scarce in
women with or without Bacterial Vaginosis. This
suggests a possible haematogenous mode of spread
from the oral cavity to the amnion. In addition to
the above, elevated levels of well known periodontal
pathogens such as Actinobacillus actinomycetem
comitans, Porphyromonas gingivalis, Tanerella
forsythia, Treponema denticola11 are noted. Also,
treatment aimed at reducing this inflammation has
Porphyromonas gingivalis and Streptococcus sanguis

,also found commonly in the dental plaque contain
Platelet Aggregation Associated Protein (PAAP),
which causes binding of the platelets within the
vessels promoting thrombus formation. This seems
to exert changes in the Blood Pressure, ECG, Heart
rate and Cardiac contractility. Acute thromboembolic
events could cause serious consequences14.
The circulating Monocytes or Macrophages enter
the inner vessel wall and release Cytokines which
promote inflammation. Also, these cells ingest LDL
(Low density lipoprotein) and form Foam cells13.
The vessel wall thickens and narrows with the
proliferation of smooth muscle fibers. The rupture
of the atheromatous plaque exposes the collagen
to the circulating blood, which provoke thrombus
formation and furthermore leads to thromboembolic
events15.
Non-Haemorrhagic Stroke also can be precipitated
by periodontal disease. An increase in fibrinogen,
C-reactive protein, bacteremia, PAAP positive
6
REFERENCES:
bacterial strains can cause platelet aggregation

and furthermore, the previously mentioned
consequences16.
1. Mealey BL. Influence of periodontal infections

on systemic health. Periodontology 2000. 1999; 21:
197-209.
POSSIBLE EFFECTS ON RESPIRATORY

SYSTEM:
2. Page RC. The pathobiology of periodontal

disease may affect systemic diseases; inversion of a
paradigm. Ann Periodontol 1998; 3: 108-120.
Much research is needed in this field to shed light

on whether there is indeed any link between oral
diseases and COPD17. There seems to be no known
consensus, as some have reported conflicting data.
However, it is imperative to know that dental plaque
is a reservoir of Potential Respiratory Pathogens
which can be aspirated to Oro-pharynx leading to
Pneumonia18.
3. Seymour GJ, Ford PJ, Cullinan MP, Leishman S,

Tamazaki K et al. Relationship between periodontal
infections and systemic disease. Clin Microbiol
Infect 2007; 13(4): 3-10.
4. Kornman KS. Mapping the pathogenesis of
periodontitis: a new look. J Periodontol 2008; 79:
1560-1568.
EFFECT ON MEN HEALTH:

CHRONIC PROSTATITIS:
5. DAiuto D, Parkar M, Andreou G, Suvan J, Brett

PM, Ready D, Tonnetti MS et al. Periodontitis and
systemic inflammation, control of the local infection
is associated with a reduction in serum inflammatory
markers. J Dent Res 2004; 83: 156-160.
A recent research has found that levels of PSA, or

Prostate specific antigen secreted by the Prostate in
small amounts considerably increase in the chronic
inflammatory state generated by Periodontitis and in
prostate cancer or chronic prostatitis19.
6. Aldridge JP, Lester V, Watts TL, Collins A, Viberti

G, Wilson RF et al: Single blind studies of the effects
of improved periodontal health on metabolic control
in type I diabetes mellitus. J clin Periodontol 1995;
22:271-275.
IMPOTENCY:
Nothing can be said in particular about this, but it has
been observed that prolonged chronic inflammation,
like that found in men with periodontal disease, can
cause damage to blood vessels which can lead to
erectile dysfunction, impotence or affect his sexual
health in general (AAP)20. Outwardly it seems to be
more of a risk factor than an initiating factor, and
further research in this area is required.
7. Christgan M, Pallitzsch KD, Schmalz G, Kreiner

U, Frenzel S et al: Healing response to non-surgical
periodontal therapy in patients with diabetes mellitus,
clinical, microbiological and immunological results.
J Clin Periodontol 1998; 25: 112-124.
CONCLUSION:
8. Grossi SG, Skrepcinski FB, DeCaro T, Robertson

DC, Ho AW, Dunford RG, Genco RJ et al. Treatment
of periodontal disease in diabetics reduces glycated
hemoglobin. J Periodontol 1997; 68: 713-719.
Numerous literature reviews and an equal number

of clinical trials have so far emphasized the role
dental diseases play in instigating or magnifying the
systemic diseases or in controlling them. Though
much more studies are needed before we draw
conclusions, still it can be affirmed that periodontal
diseases certainly are risk factors for Systemic
diseases.
9. Andrews WW, Hauth JC, Goldenberg RL.

Infection and preterm birth. Am J Perinatal 2000;
17:357-365.
10. Boggess KA, Lieff S, Murtha AP, Moss K, Beck
J, Offenbacher S et al: Maternal periodontal disease
is associated with an increased risk for preeclampsia.
Obstet Gynecol 2003; 101: 227-231.
11. Gibbs RS. The relationship between infections
and adverse pregnancy outcomes: an overview. Ann
Periodontol 2001; 6(1): 153-163.
7
12. Hujoel PP, drangsholt M, Spiekerman C,

DeRouen TA. Periodontal disease and coronary
heart disease risk. Perio 2000; 284: 1406-1410.
13. Mattila KJ. Dental infections as a risk factor for
acute myocardial infarction. Eur Heart J 1993; 14:
51-53.
14. Drabngsholt MT. A new causal model of
dental diseases associated with endocarditis. Ann
Periodontol 1998; 3: 184-196.
15. Beck JD, Garcia RG, Heiss G, Vokonas PS,
Offenbacher S et al: Periodontal disease and
cardiovascular disease. J Periodontol 1996; 67:
1123-1137.
16. Grau AJ, Buggle F, Steichen-Wiehn C, Heindl S,
Bannarjee T, Seitz R et al. Clinical and biochemical
analysis in infection-associated stroke. Stroke 1995;
26: 1520-1526.
17. Hyman JJ, Reid BC. Cigarette smoking,
periodontal disease and chronic obstructive
pulmonary disease. J Periodontol 2004; 75: 9-15.
18. Terpenning M. The relationship between infection
and chronic respiratory diseases: an overview. Ann
Periodontol 2001; 6: 66-70.
19. Nishant Joshi, Nabil F Bissada, Donald Bodner,
Gregory T MacLennan, Sena Narendran, Rick
Jurevic et al. Association between periodontal
disease and prostate specific antigen levels in chronic
prostatitis patients. Journal of Periodontology 2010;
81(6):864-869.
20. Periodontal health is important to men too. Perio.
org, American academy of Periodontology. Patients
page June 2010
Original Article
Role Of Human Papillomavirus (HPV) And Its

Detection In Potentially Malignant Disorders
And Oral Squamous Cell Carcinomas
Moe Thida Htwe, Zaw Moe Thein, Swe Swe Win
Department of Oral Medicine, University of Dental Medicine, Yangon
Department of Oral Medicine, University of Dental Medicine, Mandalay
Abstract
More than 90% represent oral squamous cell

carcinoma (OSCC), which are often preceded by preexisting oral lesions termed as potentially malignant
disorders of the oral mucosa such as oral leukoplakia
(OL) and oral submucous fibrosis (OSMF) etc.
(Warnakulasuriya et al 2007, 2011).
Oral malignancy is a major global health problem

and more than 90% of these malignancies represent
oral squamous cell carcinomas (OSCCs), which are
often preceded by pre-existing oral lesions termed
as potentially malignant disorders (OPMDs) of the
oral mucosa. Although tobacco, alcohol and betel
quid chewing habit are well known risk factors for
OPMDs and OSCCs, there is evidence to indicate
that human papillomavirus (HPV) may also play
some inducing role. Human papillomavirus (HPV)
infection in OPMDs and OSCCs are controversial.
A cross-sectional laboratory based descriptive and
analytical study was performed in 62 OPMDs and
62 OSCCs. The presence of HPV infection was
detected by Polymerase Chain Reaction (PCR)
method. Buccal mucosa was the commonest site
for OPMDs [oral leukoplakia (61%) and oral
submucous fibrosis (OSMF) (81%)]. In OSCCs,
23% were found in both buccal mucosa and tongue.
Betel quid chewing habit was the commonest in
OSCC and OSMF (54.8%). HPV positivity was
only found in OSCCs about 4.8%. No significant
associations were found between HPV infection
and histological differentiation of OSCCs as well as
grade of epithelial dysplasia for OPMDs. The results
suggested that HPV did not play an important role
in oral carcinogenesis in this group of Myanmar
patients.
According to World Health Organization (WHO),

carcinoma of oral cavity in male in developing
countries, it is the 6th commonest cancer after lung,
prostrate, colorectal, stomach and bladder cancer.
In female, it is the 10th commonest cancer after
breast, colorectal, lung, stomach, uterus, cervix,
ovary, bladder and liver (Landis et al., 1999 cited in
Mehrotra and Yadav, 2006). Numerous studies
have been carried out to investigate the prevalence
of HPV in cancer of the oral cavity. Reported
estimates have ranged from 0 to 100% (Franceschi
et al., 1996; Bouda et al., 2000; Gillison and Shah,
2001; Kreimer et al., 2005).
The pathways of HPV transmission in the mucosal
lesion may be oro-genital contact by oral sex, more
than one sexual partner and prenatal transmission of
HPV to the neonatal child (Smith et al., 2007).
Prevalence of HPV in Oral Potentially Malignant
Disorders
The prevalence of HPV identification in Oral
Leukoplakia (OL), Oral Submucous Fibrosis
(OSMF) was about 33.8% (DCosta et al 1998).
The studies have reported varied results due to the
differences in samples and molecular assays utilized,
from 0% to 85% (Bouda et al., Campisi et al., 2007;
Chaudhary et al., 2009).
INTRODUCTION
Oral malignancy is a major global health problem
and it constitutes the sixth most common malignancy.
9
Prevalence of HPV in Oral Squamous cell

carcinomas
All the cases diagnosed as oral leukoplakia,

oral submucous fibrosis and oral squamous cell
carcinoma were carried to laboratories (DMR,
Lower Myanmar and Department of Oral Medicine
and Oral Pathology, Okayama, Japan) for DNA
extraction and HPV detection (high risk and low risk)
according to strict molecular laboratory guidelines.
High-risk HPV are predominantly found in OSCC.

HPV was detected in 13.5% of normal mucosa
and 26.2% of OSCC (Miller and Johnstone, 2001).
Von and Fischer (2007) suggested that the broad
spectrum PCR is a reliable method for detection of
HPV DNA.
HPV-DNA Detection by PCR
AIM
Consensus sequence primer pair within the E6 and

E7 open reading frames i.e.
To detect Human Papillomavirus (HPV) In

Potentially Malignant Disorders And Oral Squamous
Cell Carcinomas by PCR method
Forward (pU-1M)
(5-TGTCAAAAACCGTTGTGTCC-3)
MATERIALS AND METHODS
Reverse (pU-2R)
A cross sectional laboratory-based descriptive and

analytical study
(5-GAGCTGTCGCTTAATTGCTC-3)
Targeting a region of about 230 bp specific to high
and intermediate oncogenic risk HPV (type 16, 18,
31, 33, 35, 52, and 58)
PLACE OF STUDY
Department of Oral Medicine, University of Dental
Medicine, Yangon
Forward (pU-31B)
Department of Oral Surgery, University of Dental

Medicine, Yangon
(5-TGCTAATTCGGTGCTACCTG-3)
Reverse (pU-2R)
Immunology Research Division, Department of

Medical Research (Lower Myanmar), Yangon
(5-GAGCTGTCGCTTAATTGCTC-3)
Targeting a 228 bp region specific to low risk
oncogenic HPV (type 6 and 11) are used to amplify
HPV DNA.
Department of Oral Medicine and Oral pathology,

Medical and Dental University, Okayama, Japan
STUDY POPULATION
RESULTS AND DISCUSSION
Total study population was 124 cases,

62 cases of oral
(OL, OSMF) and
DISCUSSION
potentially malignant disorders
In Myanmar, many people especially males,

extensively used smokeless tobacco in the form of
betel quid. Oral habits including tobacco smoking,
betel quid chewing as well as combination of both
influenced the occurrence of OSCC, OL and OSMF.
Betel quid chewing habit was the commonest in
OSCC and OSMF (54.8%), 4.8% of OSCC patients
had no oral habits. Regarding the histological
examination in this present study, most cases of
OSCC (83.9%) were well differentiated, (16.1%)
were moderately differentiated and there was no
poorly differentiated cases.
62 cases of oral SCCs

METHODOLOGY
Patients were selected according to the selection
criteria.
After obtaining the consent from the patients, an
oral cancer assessment form was used to collect
personal data (name, age, sex, oral habit etc.) from
each patient.
All the sections obtained were stained with
haematoxylin-eosin stain according to standard
procedure.
The relatively high occurrence of mild epithelial

dysplasia of OPMDs in this study compare with the
other results might be due to the awareness of the
10
patients as well as early referral from medical and

dental professionals. Nowadays, awareness of the
patients on oral lesions is increasing and patients
are seeking for the treatment at the early stage was
also one of the reason. This early presentation might
contribute to high incidence of well-differentiated
OSCC in this study. Therefore, early recognization
plays a vital role in the prevention and early detection
of oral cancer. Sixty-two paraffin-embedded tissues
specimens for both OPMDs and OSCCs were used
for analysis of HPV DNA by PCR. HPV DNA was
not detected in oral leukoplakia or oral submucous
fibrosis.
to investigate the prevalence of HPV infection in

younger patients with OPMDs and OSCCs who
do not have any history of smoking and smokeless
tobacco, drinking alcohol or betel quid chewing
habit.
Figure (1) Distribution of types of lesion by personal
habits
HPV DNA was detected 4.8% (3 cases out of 62

cases of OSCCs). Out of 3 HPV DNA positive
OSCC cases, 2 cases were associated with betel
quid chewing habit and 1 case was without oral
habit. It was similar to the large case-control study
by Herrero et al., (2003) conducted in 9 countries
in Asia, reported as a low prevalence of HPV DNA
(3.9%).
Figure (2) Distribution of grades of epithelial

dysplasia in OL, OSMF
Wide range of the rate of detection of HPV DNA

could depend on
the population studied,
combination of sites of lesions,
different sampling methods,
different storage procedures such as fresh frozen
or

formalin fixed
(FFPET),
paraffin
embedded
Mild dysplasia was most common 67.7% in OL and

83.9% in OSMF.
tissue
Figure (3) Distribution of histological differentiation

of Oral Squamous Cell Carcinoma
technical resources utilized for HPV detection

methods (Scully, 2005).
There are problems related to difficulties in the
extraction of nucleic acids from FFPETs, especially
related to low DNA yield due to DNA degradation
and poor DNA quality (Man et al., 2001; Wu et
al., 2002; Simonato et al., 2007). DNA was more
likely to be detected in fresh-frozen than in paraffinembedded samples (Chaudhary et al., 2009). The
relationship between HPV infection and oral cancer
is very low in Myanmar. HPV infection did not play
an important role in this study group. However,
large population studies are necessary for the role of
HPV in OPMDs and OSCCs. It would be interesting
*Well differentiated was most common in OSCC

(83.9%)
11
REFERENCES
Figure (4) distribution of HPV positivity in OSCC,

Ol, OSMF.
Chaudhary, A. K., Singh, M., Sundaram,

S., Mehrotra, R. (2009). Role of human
papillomavirus and its detection in potentially
malignant and malignant head and neck lesions
: updated review. Head and Neck Oncol, 1:22.
Chow, L. T., Broker, T. R., Steinberg, B.

M. (2010). The natural history of human
papillomavirus infections of the mucosal
epithelia. APMIS, 118: pp. 422-449.
Herrero, R., Castellsague, X., Pawlita, M., et al.

(2003). Human papillomavirus and oral cancer:
the International Agency for Research on Cancer
multicenter study. J Natl Cancer Inst, 95: pp.
1772-1783.
Khot, K., Alex, S., Sharma, U. (2011). HPV

in Oral Squamous Cell Carcinoma: Where
in the Maze? International Journal of Oral &
Maxillofacial Pathology, 2: pp. 39-44.
Kreimer, A. R., Clifford, G. M., Boyle, P.,

Franceschi, S. (2005). Human papillomavirus
types in head and neck squamous cell carcinomas
worldwide: a systematic review. Cancer Epidem
Biomar, 14(2): pp. 467-475.
Mehrotra, R and Yadav, S (2006). Oral squamous

cell carcinoma: Etiology, pathogenesis and
prognostic value of genomic alterations. Indian
Journal of Cancer, 43: pp. 60-66.
Miller, C. S. and Johnstone, B. M. (2001).

Human papillomavirus as a risk factor for oral
squamous cell carcinoma: A meta-analysis,
1982-1997. Oral Surg Oral Med Oral Pathol; 91:
pp. 622-635.
Warnakulasuriya S., Kovacevic T., Madden

P. et al. (2011). Factors predicting malignant
transformation in oral potentially malignant
disorders among patients accrued over a 10-year
period in South East England. Journal of Oral
Pathology and Medicine, 40: pp. 677683.
*HPV was only detected in OSCC (4.8%) and was

not detected in OL and OSMF
FIGURE (5) Agarose gel electrophoresis of the PCR
products for amplification of 230 bp HPV DNA
detection
Lane 1- molecular wt. maker (230 bp),

Lane 2- Negative control,
Lane 3- Positive control,
Lane 6- Positive OSCC case
FIGURE (6) Agarose gel electrophoresis of the PCR
products for amplification of 230 bp HPV DNA
detection
Lane 1- molecular wt. maker (230 bp),

Lane 2- Positive control,
Lane 4- Negative control,
Lane 3, 5- Positive OSCC case
12
Original Research
Epidemiological and Clinico-pathological study

of 120 cases of Oral Cancers in Myanmar 2012
Myo Min Thane, Le Le Win, Swe Swe Win
1.
2.
ACTION Study Group, Department of Medical Research (Lower Myanmar)

University of Dental Medicine, Yangon.
Abstract
Keywords : Oral Cancer-Myanmar, epidemiological,

clinic-pathological
Oral cancer is the fifth most common cancer in

ASEAN. Myanmar involves in high risk countries
where betel quid chewing and smoking habits
are very common and are strongly related to oral
cancer. The objective of this study is to determine
the epidemiological and clinic-pathological
characteristics of oral cancer. In this study, 120
patients diagnosed with oral cancer from University
of Dental Medicine, Yangon and Department
of Plastic, Oral and Maxillofacial Surgery,
Yangon General Hospital from January 2012 to
September 2012, were included. Epidemiological
characteristics,
clinical
characteristics,
and
histopathological descriptions were recorded by
using ACTION Study questionnaires forms and
WHO Oral Cancer Assessment forms. Male-female
ratio was 1.6:1. The commonest age group was 4665 years (54.17%) and the most frequent occupations
were non-skilled workers (29.67%) and followed by
agricultural, forestry and fishery trades and workers
(26.67%). Only betel quid chewer were 28.33% and
those with both betel quid chewing and smoking
habits were 17.5% and only smoking were 15.83%
respectively. Most of the patients chewed betel quid
with tobacco which were 74.68%. Squamous cell
carcinoma comprised 77.5% of all oral cancers and
buccal mucosa was the most affected site (33.33%)
and the patient with stage IV were 60%. Oral
squamous cell carcinomas were predominant and
betel quid chewing and smoking were found to be
high risk. According to their habitual pattern, buccal
mucosa was the commonest site and most of the oral
cancer cases represented with advanced stage was
due to delay referral.
Introduction
Oral cancer is the sixth most common
cancer in the world and fifth most common cancer
in ASEAN (Ferlay et al 2004, Merral et al 2012). In
South Asian and East Asian countries, oral cancer
contributes up to 50% of all new cases of cancer. In
Indian males, oral cancer is the first most common
cancer. In Sri Lanka, oral cancer ranked first in
five most common cancers (Khandekar et al 2006).
Myanmar involves in high risk countries in South
East Asia and ranked 6th position in males and 10th
position in females among all types of cancers.
It is commonly related to tobacco habits (Oo et al
2011). In Myanmar, the occurrence of oral cancer
is not clearly known where betel quid chewing
habits are widely spread. The purpose of the study
is to determine the epidemiological and clinicopathological characteristics of oral cancer.
Patients and Method
After obtaining the informed consent, 120 patients
diagnosed with oral cancer attending at University
of Dental Medicine, Yangon and Department of
Plastic, Oral and Maxillofacial Surgery, Yangon
General Hospital from January 2012 to September
2012, who recruited for Asean Costs In Oncology
Study Myanmar, were included. Patients who were
18 years and above, with first time cancer diagnosis
and willing to participate in the baseline and two
follow-up interviews were selected. Epidemiologic
characteristics,
clinical
characteristics
and
histopathological descriptions were recorded
according to WHO Oral Cancer Assessment forms
13
and ACTION Study questionnaires forms.
Figure.3. Distribution by race and ethnicity
Results
Males were more affected than females (1.55:1).
(Fig. 1).Education level of the patients were middle
and high school level (49.17% (Fig.2.) and most
were non-skill workers (29.67%). (Fig.4). Overall
tobacco users including smoking and chewing were
84.9%. Over half of the patients had poor oral hygiene
(59.17%). Squamous cell carcinoma comprised
77.5% of all oral cancers (Fig.6) and buccal mucosa
was the most affected site (33.33%).(Fig.7,7A-D).
Patients represented with stage IV oral cancer
were 60% (Fig.8). In grading of oral squamous cell
carcinomas, 83.9% were well differentiated (Fig.9).
Figure.4. Occupation of patients
Figure.1. Distribution of oral cancer by age group

and sex
Figure.5. Oral habits of patients
Figure.2. Education level of patient by sex
14
Figure.6.
cancer
Histopathological descriptions of oral
Figure.5A. Smokeless tobacco
Figure.7. Site distribution of oral cancer
Figure.8. Percentage of staging
Figure.9. Percentage of grading of squamous cell

carcinoma
Figure.5B. Tobacco smoke-cheroots and cigarettes
15
Clinical presentations of oral cancers
We are also deeply thankful to Departments Of

Oral and Maxillofacial Surgery from University
of Dental Medicine and Yangon General Hospital.
Finally our grateful thank to all patients participated
in this study, this study will not be possible without
their participations.
References
1.
Ferlay J, Pisani P, Parkin DM. GLOBOCAN
2002. Cancer incidence, mortality and prevalence
worldwide. IARC Cancer Base (2002 estimates).
Lyon: IARC Press; 2004.
2.
Khandekar S P, Bagdey P S, Tiwari R R.
Indian Journal of Community Medicine 31-33: July
- September, 2006.
3.
Kimman M, Norman R, Jan S, Kingston D,
Woodward M. The Burden of Cancer in Member
Countries of the Association of Southeast Asian
Nations (ASEAN). Asian Pacific J Cancer Prev, 13:
411-420, 2012.
4.
Oo HN, Myint YY, Maung CN, Oo PS,
Cheng J, Maruyama S, Yamazaki M, Yagi M, Sawair
FA, Saku T. Oral cancer in Myanmar: a preliminary
survey based on hospitalbased cancer registries. J Oral Pathol Med 40: 20-26,
2011.
5.
Warnakulasuriya S. Global epidemiology
of oral and oropharyngeal cancer. Oral
Oncol;45:309-316,2009.
Conclusion and Recommendation
For correspondence :
Oral squamous cell carcinomas were predominant

type and tobacco related oral habits were found
to be high risk. According to the results, buccal
mucosa was the commonest site and most of the oral
cancer cases were represented with advanced stage.
Therefore, strategies for primary prevention, oral
health promotion and health education programs
related to oral cancer and early detection should be
encouraged.
Dr. Myomin Thane

Email [email protected]
Acknowledgements
We wish to gratefully acknowledge ASEAN
Foundation for funding and George Institute for
Global Health, Australia for the technical support.
16
Original Research
A new peripheral tracing material for

mandibular complete denture impression
Aung Thu Hein1, Myat Nyan1, Than Swe1, Thein Kyu2
1
2
Department of Prosthodontics, University of Dental Medicine, Yangon

Rector, University of Dental Medicine, Yangon
Abstract
complete dentures is a multistage process that

involves a preliminary impression, a final
specialized or individualized final impression tray
and a final border impression (Heartwell, 1986
and Zarb, 1990). In fabrication of mandibular
complete denture, peripheral tracing with tracing
compound of an individual tray is an essential step
in impression making (Levin, 1984 and Zarb et. al.,
1997). Most prosthodontists accepted this method
as a standardized method for complete denture
construction. But it is time consuming and often
difficult for beginners to master as it require skill and
experience (Hayakawa, 2003). Silicone impression
material has excellent elasticity, acceptable working
time, good dimensional stability, acceptable taste
and ease of manipulation for every dentist. The
purpose of this study was to compare the retentive
forces of two mandibular base plates this fabricated
from two peripheral tracing impression materials,
compound and silicone.
Success of complete dentures largely depends on

accuracy of impression. In fabrication of mandibular
complete denture, border molding of an individual
tray is an essential step in impression making.
It can also trace the future dentures periphery by
molding the peripheral of the individual tray and
by asking the patient to make functional trimming
exercises. The individual tray obtained from a
preliminary impression are border molded with
modeling compound, and final impression is
completed with easily flowable impression material
such as zincoxide eugenol paste. By using this
border molding and peripheral tracing impression
technique, resultant mandibular complete denture
favors good retention and stability even in resorbed
alveolar ridge. Most prosthodontists accepted this
method as a standardized method for complete
denture construction. But it is time consuming and
often difficult for beginners to master as it require
skill and experience. In this study, high viscosity
silicone (putty) and light body silicone have been
introduced as a new border molding material. It
was found that the retention of two base plates
resulted from impression making with these two
border molding materials were not statistically
significant (mean 367 gf for compound and 368 gf
for silicone). Silicone impression material has an
excellent elasticity and acceptable working time in
the mouth during functional trimming. It also has
good dimensional stability, acceptable taste and ease
of manipulation for every dentist.
Material and Methods: The primary impression

was made with impression compound (Hiflex
Impression Compound) then constructed the
acrylic close fitting special tray and molded along
the periphery with tracing compound for standard
technique and heavy-bodied silicone (Speedax,
coltene, whaledent) for research technique. Final
impression was made with zincoxide eugenol
(Synident Zincogenol) for compound tracing and
light bodied silicone for silicone tracing. The two
base plates were constructed for each technique in
a patient. Retentive forces of these two base plates
were measured in the patients mouth by using pushpull gauge. Statistical comparison of test results was
performed by using t-test.
Introduction: Success of complete dentures largely

depends on accuracy of impression (Hayakawa,
2003). Making accurate final impression for
17
Figure 1 and 2. Peripheral Tracing with tracing compound
Figure 3. Peripheral Tracing with silicone
Figure 4. Clinical Procedure
Figure 5. Base plate constructed from impressions
Results: Retention values of two base plates fabricated from the casts obtained from two impression materials,
(mean 367 gf for compound, standard technique and 368 gf for silicone) were not significant.
Figure 6. Comparison of retentive forces of two base plates which obtained from different materials
18
Table 1. Statistical Analysis
Discussion: Border molding impression trays by

modeling plastic has been used since 1907 (Sanjeev,
2012). Around 1950, border molding with tracing
compound was accepted as standardized technique
by most prosthodontists (Craddock, 1951). Various
surveys showed modeling plastic impression
compound and zincoxide eugenol impression paste
is most popular material used for complete denture
impression. But there is distinct trend for increasing
use of polyvinyl siloxane and polyether for border
molding procedures and impression of edentulous
arches. In literature, various author reported the use
of elastomer for border molding and final impression.
Woelfel et. al., (1963) reported that it required an
average of 17 placements to obtained a maxillary
final impression using modeling compound as
the border molding material. It became the major
drawback of this technique. Smith et. al., (1979)
described a technique using a polyether impression
material for border molding the final impression
trays. The major advantages of this technique were
that the border molding could be accomplished in
one-step and the patients functional movements
were utilized to form the borders. Tan et. al., (1996)
concluded that polyether impression material
required less time to complete the border molding
process, border recorded were longer and less
operator variability when compared with modeling
compound. Lu et. al., (2004) and Appelbaum et. al.,
(1984) concluded that polyvinyl siloxane putty and
light body impression material are well suited for
making complete denture impression. Good results
are obtained with less expenditure of time as well
as less discomfort and inconvenience for the patient,
especially in the hands of an inexperienced operator.
borders with one insertion of the tray, easy technique,

patients comfort and good dimensional stability
(Rizk, 2008). Additional superior advantages to
the standardized compound tracing technique were
uniform consistency and accurate reproduction of
undercut areas. This study compared the retention
of two denture base plates obtained from tracing
compound with zincoxide eugenol and silicone
putty with light body wash. It was found that both
retentions were satisfactory and no statistically
significant difference between two materials.
Because of its advantages, silicone are definitely
going to replace the traditional impression materials.
Conclusion: Silicone may applicable as peripheral
tracing impression material in complete denture
construction alternative to the standardized technique
with tracing compound.
Using silicone as a peripheral tracing impression

material was first introduced by Smith (1979). It
has the advantages of simultaneous molding of all
19
References
Appelbaum, E.M., Mehra, R.V., (1984). Clinical
evaluation of polyvinyl siloxane for complete
denture impression. J Prosthet Dent, 52, pp. 537539.
Craddock, F.W., (1951). Prosthetic dentistry; a
clinical outline. St. Louis: CV Mosby.
Hayakawa, I., (2003). Impression for complete
dentures using silicone impression materials.
Quintessence Int, 34, pp. 177-180.
Levin, B., (1984). Impression for Complete Dentures.
Chicago: Quintessence.
Lu, H., Nguyen, B., Powers, J.M., (2004).
Mechanical properties of 3 hydrophilic addition
silicone and polyether elastomeric impression
materials. J Prosthet Dent, 92, pp. 151-154.
Rizk, F., (2008). Effect of different border molding
materials on complete denture retention. Cairo
Dental Journal. 3, pp. 415-420.
Sanjeev, M., (2012). Single step silicone border
molding technique for edentulous impression. Int J
of Clinical Cases and Investigations. 4(2), pp. 8590.
Smith, D., (1979). One-step border molding of
complete denture impressions using a polyether
impression material. J Prosthet Dent. 41, p. 347.
Tan, H.K., Hooper, P.M., Baergen, C.G., (1996).
Variability in the shape of maxillary vestibular
impression recorded with modeling plastic and a
polyether impression material. Int J Prosthodont, 9,
pp. 282-289.
Woelfel, J.B., (1963). Contour variations in one
patients impression made by seven dentists. J Am
Dent Assoc, 67, pp. 1-9.
Zarb,G.A.; Bolender, C.L. and Carlsson, G.E.,
(1997). Bouchers Prosthodontic Treatment for
Edentulous Patients. 11th Edition. St. Louis: CV
Mosby.
20
Original Research
Effect of mixing methods and disinfection on

dimensional accuracy of alginate impression
Thida Phyo1 and Myat Nyan2
1
2
Private practitioner, Sakura Dental Implant Centre, Yangon, Myanmar.

Department of Prosthodontics, University of Dental Medicine, Yangon, Myanmar.
Abstract:
Automatic mixing and subsequent disinfection by

soaking in 0.5% sodium hypochlorite solution is
preferred for more accurate alginate impressions.
Commercial mechanical mixers for mixing alginate

impression materials are available in Myanmar
dental market and they are more convenient and
more consistent for the practitioner; however, there
is very little information on the mechanical property
of alginate mixed with device as compared with
hand-mixing. Moreover, there is limited knowledge
on dimensional changes after disinfection of automixed alginates. This study was performed to study
the dimensional accuracy of alginate impressions
mixed by different methods with or without soaking
in disinfection solution.
Introduction
Anatomical models are used for many diagnostic
and treatment purposes in the dental practice. A
dimensionally accurate impression, i.e. a negative
mould of the jaw, is important for fabricating a
precise anatomical model. The most commonly
used impression material is alginate, irreversible
hydrocolloid material. Alginates were originally
developed in the 1930s (Doubleday, 1998). The
main advantages of alginates are the ease of use,
cost-effectiveness, their hydrophilic characteristics,
and the good patient acceptability (Frey et al., 2005).
Although alginate is easy to manipulate, the correct
handling (water/powder ratio, spatulation) affects
dimensional accuracy of the material. Therefore, it is
imperative to follow the manufacturers prescriptions
on mixing (Caswell et al., 1986; Frey et al., 2005).
Commercially available alginate impression material

(Kromopan, Lascod, Italy) was mixed by mechanical
mixer (DB-988+, Coxo Medical Instrument Co.
Ltd.) or hand-mixed according to manufacturers
recommended water powder ratio. Metal impression
tray of appropriate size was loaded with mixed
impression material and impression was made on
plastic typodont model. Then after washing under
running water, they were soaked in 0.5 % sodium
hypochlorite solution for 10 minutes and then rinsed
under running for 1 minute (disinfection, n=10) or
cast immediately (control, n=10). Impressions were
cast with dental stone (Fuji Rock, GC Co. Ltd.,
Tokyo, Japan). Tooth length and saddle length were
measured with digital slide clipper. Unpaired T test
was employed to analyze data.
Nowadays, high-speed rotary mixing instruments

for alginate impression materials are available to be
used in a dental practice. These instruments easily
produce a fine paste low in air bubbles compared
with paste mixed by hand. Therefore, it is estimated
that paste obtained by this method possesses superior
rheological properties by reducing the number and
volume of porosities in the mixed alginate (Inoue et
al., 2002).
Significant differences were found between automixed and hand-mixed samples and between
control and disinfection samples. Automatic mixing
with disinfection gave casts that were the closest
representation of actual model.
In addition, dental impressions become contaminated

with the microorganisms from saliva and blood
of the patients that can cross-infect gypsum casts
poured against them (Chau et al., 1995). This
potential of cross-contamination between clinical
21
area and laboratory must be reduced (Sofou et al.,

2002). Sterilization of impressions by dry or moist
heat is unsuitable for alginates and therefore cold
disinfection must be used for this purpose (Conner,
1991). As the necessity for disinfecting impressions
has become apparent, it has also become clear that
the process itself should have no adverse impact
on the dimensional accuracy and surface texture
features of the impression material and resultant
gypsum cast (Ahmad et al., 2007). The ideal
disinfection procedure must leave the physical and
chemical properties of the impression material and
gypsum unchanged to achieve optimal accuracy of
the final casts and the appliances made on the casts.
millimeter (mm).
The aim of this study was to quantify the effect of

hand-mixing and automatic mixing technique with
or without the use of a disinfectant on dimensional
accuracy of alginate impression.
Figure (2) DB-988 Alginate mixer
Figure (1) Partially edentulous typodont model
Materials and Methods

A partially edentulous typodont model (Figure 1) was
used to take the impression with alginate impression
material.
Commercially
available
alginate
impression material (Kromopan, Lascod, Italy)
was mixed by mechanical mixer (DB-988+, Coxo
Medical Instrument Co. Ltd.) (Figure 2) or handmixed according to manufacturers recommended
water powder ratio. Metal impression tray of
appropriate size was loaded with mixed impression
material and impression was made on plastic model.
Then after washing under running water, they were
soaked in 0.5 % sodium hypochlorite solution for 10
minutes and then rinsed under running for 1 minute
(disinfection, n=10) or cast immediately (control,
n=10). Impressions were cast with dental stone (Fuji
Rock, GC Co. Ltd., Tokyo, Japan).
Figure (3) Digital slide clipper
Six measurements were done for each cast sample

by measuring teeth lengths (anterior, premolar,
molar) and lengths of edentulous spans (anterior,
premolar and molar regions) by using a digital slide
clipper (Figure 3). Measured data was registered
in spreadsheet program (Microsoft Excel, Version
2007) and examined by using Unpaired Samples T
test in SPSS (Statistical Package for Social Science)
statistical software. The values of change between
measurements from sample casts and measurements
directly taken from the typodont model were
calculated and expressed as a linear change in
22
Result
Table (1) Measurements of typodont model and sample casts (hand-mixing
method)
Typodont model
Sample casts without subsequent

disinfection
Anterior
Premolar Molar
Anterior
Mean
(SD)
Premolar
Mean
(SD)
Molar
Mean
(SD)
Anterior
Mean
(SD)
Premolar
Mean
(SD)
Molar
Mean
(SD)
Tooth length
11.13
8.8
6.62
10.97
(0.07874)
8.51
(0.091378)
6.376
(0.013416)
11.042
(0.034205)
8.512
(0.050695)
6.496
(0.082037)
Edentulous
span length
9.08
14.28
16.63
9.108
(0.027749)
14.372
(0.099348)
16.762
(0.076616)
9.184
(0.074027)
14.55
(0.082765)
16.828
(0.112561)
Measurements
Sample casts with subsequent

disinfection
Table (2) Measurements of typodont model and sample casts (automatic mixing
method)
Typodont model
Sample casts without subsequent

disinfection
Sample casts with subsequent

disinfection
Anterior
Premolar Molar
Anterior
Mean
(SD)
Premolar
Mean
(SD)
Molar
Mean
(SD)
Anterior
Mean
(SD)
Premolar
Mean
(SD)
Molar
Mean
(SD)
Tooth length
11.13
8.8
6.62
11.078
(0.040866)
8.566
(0.065038)
6.518
(0.072595)
11.086
(0.06269)
8.636
(0.069857)
6.596
(0.02881)
Edentulous
span length
9.08
14.28
16.63
9.078
(0.034928)
14.332
(0.042661)
16.726
(0.078613)
9.152
(0.056303)
14.476
(0.086776)
16.8
(0.091924)
Measurements
23
Figure (4) The amount of change of tooth length

in the sample casts with or without subsequent
disinfection. Error bars denote standard deviation.
*p<0.05
represents
statistically
significant
differences.
Figure (5) The amount of change of edentulous

span length in the sample casts with or without
subsequent disinfection. Error bars denote standard
deviation. *p<0.05 represents statistically significant
differences.
24
Tooth length of all sample casts became shorter

than that of typodont model (maximum 0.29 mm).
Significant differences were found at anterior and
molar tooth length of auto-mixed samples with
subsequent disinfection.
0.5% sodium hypochlorite solution was chosen as a

disinfectant in our study. It has strong and immediate
antimicrobial effect, cost effectiveness and is easily
available in the market. Alginate impressions do
not tolerate the heat treatment; therefore chemical
disinfection has been the method of choice (Ahmad
et al., 2007). Immersion seems to be more secure than
spraying (Kotsiomiti et al., 2008). As irreversible
hydrocolloid has a tendency to be superficially
dissolved in sodium hypochlorite, hydrocolloids
should be disinfected for a limited time (Dreesen et
al., 2012).
Nevertheless, edentulous span of all samples was

longer than that of actual model (maximum 0.27
mm). Although significant differences were seen
at anterior of both auto-mixed and hand-mixed
samples without subsequent disinfection, there
were no significant differences in the samples with
subsequent disinfection.
In the present study, there was contradictory result

regarding the effect of disinfection. Although
disinfection gave casts with teeth that were the
closest representation of actual model than without
disinfection (especially with auto-mixing), for
edentulous span length disinfection showed negative
effect i.e. the span became longer than those without
disinfection. Nevertheless, auto-mixing without
disinfection resulted in the casts with the least
change in edentulous span length. It is assumed that
alginate materials prepared with manual method
produce more porosity and more absorption of water
(imbibition) can affect the precision of the impression
and may result in inaccurate casts. Although the
differences between the mixing methods with or
without disinfection are found to be significant,
the preference for device mixing is not only to
standardize the alginate mixing procedure but also
to facilitate the mixing, to reduce the amount of air
bubbles, to obtain a homogenous mixture (Dreesen
K et al., 2012).
Discussion
The statistical analysis showed that significant
differences were found in cast dimension and tooth
lengths between two mixing methods with or without
disinfection. Alginate impressions prepared with
automatic mixing method have better dimensional
accuracy than those mixed by hand. Koski showed
that alginate mixed with the device produced fewer
surface defects and had better detail reproduction
with cast gypsum than hand-mixing (Koski,
1997). Inoue et al. (2002) investigated the setting
characteristics and rheological properties of alginate
mixed by three methods: a hand-mixing technique,
a semi-automatic mixing instrument, and an automixed instrument. They found almost no porosities
using the auto-mixed instrument and concluded
that in clinical use, homogenous mix produced by
auto-mixed is preferred over hand mixing (Inoue et
al., 2002). Frey et al. (2005) used the Alginator II
(Cadco, Oxnard, CA), a semi-automatic mixer and
observed similar findings.
Conclusion
However, it is noted that the working time of

automatically mixed paste was significantly
decreased. It may be because when the material
is mixed at high speed, the temperature of the
paste increases slightly due to friction between the
material and mixing container. Similarly Inoue et al.
(2002) showed that pastes mixed automatically had a
markedly shorter working and setting time compared
with hand-mixing. Disinfection of impressions has
been taken for a topic of importance for a number
of years. American Dental Association (1994)
recommended a ten-minute immersion in a 1:10
dilution (0.525%) of sodium hypochlorite solution
for disinfection of hydrocolloid impressions. So,
Within the limitation of the present study, it can

be concluded that auto-mixing is preferable for
more accurate alginate impression and subsequent
disinfection with 0.5% sodium hypochlorite solution
for 10 minutes has little effect on dimensional
accuracy.
25
References
Ahmad S, Tredwin C J, Nesbit M, Moles D R 2007
Effect of immersion disinfection with Perform-ID
on alginate, an alginate alternative, an additioncured silicone and resultant type 3 gypsum casts
Caswell C W, von Gonten A S, Meng T R 1986
Volumetric proportioning techniques for irreversible
hydrocolloids: a comparative study. Journal of
American Dental Association 112:859-861
Chau V B, Saunders T R, Pimsler M, Elfring D R
1995 In depth disinfection of acrylic resins. Journal
of Prosthetic Dentistry 74:309-313
Conner C 1991 Cross-contamination control
in prosthodontic practice. Journal of Prosthetic
Dentistry 4: 337-344
Dreesen K, Kellens A, Weavers M, Pushpike JT,
Willems G. The influence of mixing methods and
disinfectant on the physical properties of alginate
impression material. Eur J Orthod 2012; 10:1-7
Doubleday D 1998 Orthodontic products update.
British Journal Orthodontics 25: 133-140
Frey G, Lu H, Powers J 2005 Effect of mixing
methods on mechanical properties of alginate
impression materials. Journal of Prosthodontics 14:
221-225
Inoue K, Song Y X, Kamiunten O, Oku J, Terao T,
Fuji K 2002 Effect of mixing methods on rheological
properties of alginate impression materials. Journal
of Oral Rehabilitation 29: 615-619
Kotsiomiti E, Tzialla A, Hatjivasiliou K 2008
Accuracy and stability of impression materials
subjected to chemical disinfection-a literature
review. Journal of Rehabilitation 35:291-299
Sofou A, Larsen T, Fiehn N E, Owall B 2002
Contamination level of alginate impression arriving
at a dental laboratory. Clinical Oral Investigation 6:
161-165
26
Original Research
An in vitro study on coronal microleakage of

endodontic acess cavity using single seal and
double seal techniques
Phyu Phyu Aung, Aung Thein Tun, Myint Myint San, Aung Htang
1
2
Department of Conservative Dentistry, University of Dental Medicine, Mandalay

Department of Conservative Dentistry, University of Dental Mendicine, Yangon
Abstract
Introduction
The purpose of this study was to compare the

sealing ability of the two temporary restorative
materials: Caviton and Kalzinol, and to compare
the sealing ability of single and double sealing
technique. Endodontic access cavities were prepared
in eighty extracted human mandibular molar teeth.
They were divided into 4 groups. In group (I) the
access cavities were restored with Caviton alone, in
group (II) the access cavities were restored with
Kalzinole alone, in group (III) 2 mm of gutta-percha
temporary stopping was placed as an underlying
material within the pulp chamber and then Caviton
was placed as the external material, in group (IV) - 2
mm of gutta-percha temporary stopping was within
the pulp chamber and then Kalzinol was placed as
the external material.
Root canal treatment can be carried out in a single

visit or multiple visits. Mostly, single visit root canal
therapy is carried out for vital, non-infected cases.
Whilst multiple visit root canal therapy is indicated
for cases with infected canals. Therefore, complete
sealing of the endodontic access opening between
appointments is an essential element to achieve
endodontic success.
Many clinical cases with infected canals require
dressing with antibacterial medicaments in a
multivisit treatment in which effective temporization
for different periods of time becomes mandatory
(Sjgrene, et. al., 1997). Temporary restorative
materials must provide an adequate seal against
ingress of bacteria, fluids and organic materials
from the oral cavity to the root-canal system, and
at the same time prevent seepage of intracanal
medicaments.
After restoring the access cavities, the teeth were

immersed in 2% methylene blue dye solution for 2
days and 7 days intervals. Then, they were split into
halves mesiodistally, and the dye penetration was
assessed by using magnifying glass at magnification
of x3. The data were subjected to stastical analysis
by using SPSS software version 16, using KruskalWallis test, Mann-Whitney test and Tukey HSD
test. According to the result, Caviton provided
better sealing ability than that of Kalzinol in both
immersion periods, and there is no significant
difference between single sealing technique and
double sealing technique.
Nowadays, a wide variety of temporary

restorative materials is available to the
profession. They are usually grouped based on
their prime constituents such as (1) Zinc oxide
containing cements: Zinc phosphate cement, Zinc
polycarboxylate cement, conventional Zinc oxide
eugenol cement, reinforced Zinc oxide eugenol
cement (IRM and Kalzinol etc), Zinc oxide and
calcium sulphate preparation (Caviton and Cavit,
etc), (2) Glass ionomer cement and (3) Light
cured composite material formulated as temporary
endodontic restorative material (TERM).
27
In the present in vitro study, Caviton and Kalzinol

were selected to compare the microleakage of
single seal technique and double seal technique in
endodontic access cavity.
For complete setting, all the specimens were placed

in distilled water at 37C for 48 hours. After 48
hours, all the specimens were taken out and allowed
to air dry. Then the specimens were coated with
double layers of nail varnish to all surfaces expect
1mm around the restorative margin. The first layer
of nail varnish was allowed to dry thoroughly before
applying second layer. After that all the specimens
were coated with melted modelling wax in same
manner as nail varnish was applied.Then all the
specimens were immersed in methylene blue dye
solution for 2 days and 7 days intervals (figure 2).
Materials and Methods

Eighty extracted human mandibular molars with no
carious lesion, small and moderately extent class I
carious lesion were collected from Department of
Oral and Maxillofacial Surgery, University of Dental
Medicine, Yangon and Out Patient Department of
Thingankyun Sanpya, Hospital. During the period
of sample collection, the teeth were stored in 10%
formalin solution. After completing the collection,
the teeth were thoroughly washed under running
tap water and immersed in 5% sodium hypochlorite
solution for disinfection and removing soft tissues
adhered to the root surface. The hard deposits on the
tooth surface were removed with hand scaler.
All the teeth were randomly divided into four
experimental groups and each group contained
twenty teeth. The access cavities of each group were
prepared, and restored as follow-
Figure 2. Specimens were immersed in methylene

blue dye solution
Group I - all the teeth were restored with Caviton

alone
Table 1. Experimental groups for 2 days interval
Group II - all the teeth were restored with Kalzinol

alone
Groups
Group III - all the teeth were restored with gutta percha temporary stopping and Caviton
Group IV- all the teeth were restored with gutta percha temporary stopping and Kalzinol.
After the placement of the temporary restorative
materials into the prepared access cavities, the
radiographs of all specimens were taken to verify the
quality of coronal temporary restoration (figure 1).
Materials
Teeth
Caviton
10
II
Kalzinol
10
III
Caviton and gutta-percha
10
IV
Kalzinol and gutta-percha
10
Table 2. Experimental groups for 7 days interval

Groups
Materials
Teeth
Caviton
10
II
Kalzinol
10
III
Caviton and gutta-percha
10
IV
Kalzinol and gutta-percha
10
After 2 days and 7 days respectively, the teeth were

removed from the dye and washed under running tap
water. The specimens were split in half in mesiodistal
Figure 1. radiographic representations of coronal

temporary restoration
28
direction, and the greatest dye pentration at the tooth

surface was recorded. The depth of dye penetration
was evaluated according to the following scoring
system.
Table 3. The results of the comparison between the

microleakage of 2 days versus 7 days for each group
by using Mann-Whitney U Test at a significant level
of p= 0.05.
Score 0 = no dye penetration
Groups
Score 1 = staining from occlusal surface up to onethird of the cavity wall

Score 2 = staining from occlusal surface up to twothird of the cavity wall
Score 3 = staining from occlusal surface up to more
than two-thire of the cavity wall
Score 4 = staining to cotton pellets in root canal
orifices
Materials
Mean Ranks
2 days
7 days
p Value
Caviton
6.80
14.20
0.002*
II
Kalzinol
5.50
15.50
0.001*
III
Caviton &
gutta-percha
7.05
13.95
0.005*
IV
Kalzinol &
gutta-percha
5.50
15.50
0.001*
(*) indicates statistically significant differences at

p=0.05.
The dye penetration of each specimen was measured

by two examiners using magnifying glass at a
magnification of x3. When there was interexaminer
variation on scoring certain samples, an agreement
for the score was obtained after a discussion between
the two examiners.
The results of statistical analysis made with MannWhitney U Test for the four experimental groups, as
a function of two immersion periods, in dye solution
are given in Table 3. At a significant level of p=0.05,
there was statistically significant difference between
two days immersion and 7 days immersion in
microleakage of each experimental group.
The data were statistically analysed by SPSS

software version. 16, using Kruskal-Wallis Test,
Mann-Whitney Test and Tukey HSD Test.
Table 4. Mean ranks of the leakage scores measured

as linear dye penetration for the temporary restorative
materials in each experimental group (2 days).
Results
In this study, the coronal microleakage in all
specimens was determined by measuring the extent
of linear dye penetration from margin of prepared
endodontic access cavity to floor of the pulp chamber.
Groups
Materials
Mean ranks
(2 days)
Caviton
11.3a
II
Kalzinol
28.25b
III
Caviton & gutta-percha
12.95a
IV
Kalzinol & gutta-percha
29.5b
p value
0.001
Same letters indicate no statistical significant

difference at p=0.05.
In Table 4, statistical analysis made with KruskalWallis Test at significant level of p=0.05 for two
days results were given, and there was statistically
significant difference among four experimental
groups on 2 days interval (p=0.001).
Figure 3. Photographic representation of dye
penetration in double and single sealing techniques
29
Table 5. Mean ranks of the leakage scores measured

as linear dye penetration for the temporary restorative
materials in each experimental group (7 days).
Caviton
10.05c
II
Kalzinol
30.5d
Table 6 and 7. According to the results, Caviton

containing groups, i.e., group I and III, showed less
microleakage than Kalzinol containing groups, i.e.,
group II and IV (p=0.001). Although gutta-percha
temporary stopping material was placed beneath the
Caviton and Kalzinol respectively in double sealing
technique, marginal leakage was not significantly
improved.
III
Caviton & gutta-percha
10.95c
Discussion
IV
Kalzinol & gutta-percha
30.5
After the initial chemomechanical phase of root

canal treatment, the quality of coronal restoration
seems to be the most important for periapical health
of the tooth. Invasion of microorganisms into the
pulpal space during endodontic therapy reduces the
rate of success (Engstrom cited in Friedman, 1986).
Todd & Harrison (1979) suggested that the interface
between tooth substance and temporary restorative
materials served as a pathway of leakage from the
oral cavity into the pulp chamber. Therefore the
sealing ability of temporary restorative materials
used in endodontic therapy is important for the
success of therapy.
Groups
Materials
p value
Mean ranks
(7days)
0.001
Same letters indicate no statistical significant

difference at p=0.05.
According to statistical analysis made by using
Kruskal-Wallis Test at a significant level of p=0.05
(Table 5), statistically significant difference was
observed among four experimental groups on 7 days
interval (p=0.001).
Table 6. The results of multiple comparisons between
groups carried out by Tukey HSD Test at 95%
confidence interval for the specimens immersed in
dye solution for 2 days interval.
Group I
Group II
Group III
Group IV
0.001*
0.965
0.001*
0.001*
0.965
Group II
Group III
In the present study, Caviton was observed more

water tight seal than Kalzinol in both 2 days and
7 days intervals. The result of present study was
in accordance with the number of studies which
reported Caviton, Zinc oxide/calcium sulphate
preparation, provided superior seal than Kalzinol
and IRM which are reinforced Zinc oxide eugenol
materials (Lee, et al., (1993) & Pai, et. al., (1999).
Cruz, et. al., (2002) also showed that Caviton
provided the better seal than Cavit which is a variant
of Zinc oxide/calcium sulphate preparation.
0.001*
(*) indicates statisticaly significant differences at

p=0.05
Table 7. The results of multiple comparisons between
groups carried out by Tukey HSD at 95% confidence
interval for the specimens immersed in dye solution
for 7 days interval.
Group I
Group II
Group III
Group II
Group III
Group IV
0.001*
0.952
0.001*
0.001*
1.000
The result of Kalzinol in this study was inferior to that

of Caviton, and was in contrary to Friedman (1986)
and Jacquot (1996) who showed that reinforced Zinc
oxide eugenol provided more water tight seal than
Zinc oxide/calcium sulphate preparation. However,
the present study agreed with the results of the
study performed by Tewari (2002). In that study, the
severity of the leakage increased from the first day
onward and on the seventh day total dye leakage was
found in all teeth which were restored with Kalzinol.
0.001*
(*) indicates statistically significant differences at

p=0.05.
The possible explanation for these observed results

are: (1) Caviton is premixed material and this factor
may reduce the inconsistencies related to chair-side
The results of Post-Hoc test made by using Tukey

HSD test at 95% confidence interval are given in
30
Conclusion
manipulation, and can be condensed properly against

the cavity walls; (2) the dimensional stability of
temporary restorative material depends on its water
content. Widerman (1971) showed that Cavit has
high linear hygroscopic expansion, probably caused
by water absorption during setting. This expansion
enhances the contact between the material and
the dentinal walls, and also produces a better seal.
Because of a variant of Zinc oxide/calcium sulphate
preparation Caviton also possesses high linear
expansion when it contacts with saliva in oral cavity
or moisture, thereby preventing seepage of bacteria
and promoting the success of root canal treatment.
According to the results obtained from this

experimental
investigation,
the
following
conclusions are drawn:
1. Both temporary restorative materials,
namely Caviton and Kalzinol, leaked significantly
at 7 days immersion period when compared with
the leakage results of 2 days immersion. It implies
that the microleakage of these temporary restorative
materials increases with extended storage period.
2.
For both immersion periods, 2 days versus
7 days, Caviton temporary restorative material
exhibited superior sealing ability than did its
counterpart, Kalzinol cement.
In the present study, dye penetration into the

material was noted in Caviton cement, and not in
Kalzinol cement. It might be due to the fact that
calcium sulphate, the main ingredient in Caviton,
is hydrophilic; possibly, the material absorbs water
from aqueous solution of the dye (Tasme, 1982).
Eugenol, added to materials with a Zinc oxide
powder, is oily substance and sometimes it remains
free after the cement sets (Biven, 1972). Therefore,
dye cannot penetrate into the material, and it only
penetrates into the dentin-restoration interface.
3.
For both temporary restorative materials,
viz, Caviton and Kalzinol, placement of gutta-percha
temporary stopping material as an additional layer
beneath each temporary restorative material to seal
the coronal access cavity did not improve the sealing
ability of each material at the two tested periods.
4.
Either Caviton or Kalzinol has to be chosen
as a temporary restorative material to seal the access
cavity; it is unwise to keep them in situ even up to
one week.
In this study, double sealing technique employing

gutta-percha as additional layer before placement
of Caviton and Kalzinol respectively did not
improved the sealing ability, when compared to a
Caviton alone or Kalzinol alone. The result of the
present study was consistent with the result of the
study performed by Gekelman (1999) who showed
that the used of gutta-percha layer under Cimpat,
which is a hygroscopic material similar to Caviton,
did not motivate any improvement to the seal of the
restoration.
References
Biven, G.M., Bapna, M.S., Heuer, M.A., (1972).
Effect of eugenol and eugenol-containing root canal
sealers on the microhardness of human dentin.
Journal of Dental Research.52: pp.1602-1609.
Cruz, E.V., Shigetani, Y., Ishikawa, K., Kota, K.,
Iwaku, M., Goodis, H.E., (2002). A laboratory
study of coronal microleakage using four temporary
restorative materials. International Endodontic
Journal. 35: pp. 315-320.
The possible explanations for sealing or leaking

result might be due to material which possesses
following properties: (1) high thermal expansion, (2)
poor adaptation to the cavity wall, and (3) shrinks
when used with heat or a solvent.
Friedman, S., Shani, J., Stabholz, A., Kaplaw, J.,

(1986) . Comparative sealing ability of temporary
filling materials evaluated by leakage of radiosodium.
International Endodontic Journal. 19: pp. 187-193.
The results of the present study refer only to an

in vitro condition. Clinically, the result could be
influenced by the masticatory forces and thermal
fluctuation present in oral cavity.
Gekelman, D., Deonzio, M.D.A., Prokopowitsch, I.,

Gavini, G., (1999). Microleakage of four temporary
endodontic sealings after thermocycling. Ecler
Endod. 1: pp. 1-9.
31
Jacquot, B.M., Panighi, M.M., Steinmetz, P., Sell, C.

G., (1996). Microleakage of Cavit, Cavit-W, Cavit-G
and IRM by impedance spectroscopy. International
Endodontic Journal. 29: pp. 256-261.
Lee, Y.C., Yang, S.F., Hwang, Y.F., Chueh, L.H.,
Chung, K.H., (1993). Microleakage of endodontic
temporary restorative materials. Journal of
Endodontics. 19: pp. 516-520.
Pai, S.F., Yang, S.F., Sue, L.W., Chueh, L.H., Rivera,
E.M., (1999). Microleakage between endodontic
temporary restorative materials placed at different
times. Journal of Endodontics. 25: pp. 453-456.
Sjgren, U., Figdor, D., Persson, S., Sundqvist, G.,
(1997). Influence of infection at the time of root
filling on the outcome of endodontic treatment
of teeth with apical periodontitis. International
endodontic journal. 30: pp. 297-306.
Tamse, A., Ben-Amar, A., Gover, A., (1982).
Sealing properties of temporary filling materials
used in endodontics. Journal of Endodontics. 8: pp.
322-325.
Tewari, S., Tewari, S., Rohtak., Haryana.,
(2002). Assessment of coronal microleakage in
intermediately restored endodontic access cavities.
Oral Surgery, Oral Medicine, Oral Pathology, Oral
Radiology, and Endodontology. 93: pp. 716-719.
Widerman, F.H., Eames, W.B., Serene, T.P., (1971).
The physical and biologic properties of Cavit.
Journal of American Dental Association. 82: pp.
378-382.
32
Original research
A comparative study on the dimensional

accuracy of two types of elastomeric
impression materials
San Thida Nyunt 1, Win Lwin 2 and Myint Myint San 3
Department of Conservative Dentistry, University of Dental Medicine, Yangon
Department of Conservative Dentistry, University of Dental Medicine, Mandalay
3
Department of Conservative Dentistry, University of Dental Medicine, Yangon
1
ABSTRACT
were significantly greater than that of Aquasil

impression material (p < 0.05). This study showed
the addition silicone impression material was more
dimensionally accurate than the condensation
silicone impression material.
Dimensional accuracy of impression materials

is crucial to the quality of fixed prosthodontic
treatment. Successful crown and bridge works
depend on accurate impressions. The aim of this
study was to investigate the dimensional accuracy
of two types of elastomeric impression materials,
addition silicone and condensation silicone on two
stainless steel master dies, 6 and 18 total occlusal
convergence angles. For each master die, impressions
were taken ten times with each impression material.
The sample consisted of (40) stone dies. Type IV
stone was poured into the impressions. The diameter
and height of stainless steel master dies and stone
dies were measured by using the digital caliper
(accurate to 0.01 mm). The mean measurements
of stone dies casted from different impression
materials were recorded and diameter discrepancies
and vertical height discrepancies were calculated.
Mean percentage of deviations from the master dies
for each test group were also calculated. The results
were tabulated and analyzed by using unpaired t
test. According to results of present study, there
were greater diameter and vertical height of stone
dies than stainless steel master dies by using Aquasil
impression material. There were larger diameter but
smaller vertical height of stone dies than stainless
steel master dies by using Zetaplus impression
material. The mean values of diameter and vertical
height discrepancies and percentage of deviations of
the samples that reproduced from master die 1 and
master die 2 by using Zetaplus impression material
INTRODUCTION
Successful crown and bridge works depend on
accurate impressions. Making the impressions
to duplicate the prepared tooth morphology and
surrounding tissues is an integral part of fixed
prosthodontic procedure. The clinical success of
fixed prosthodontic procedure is dependent, in
part, upon the dimensional accuracy of elastomeric
impression materials and impression procedures.
Therefore, dimensional accuracy of impression
materials is crucial to the quality of fixed
prosthodontic treatment.
When considering the replication process of which
impression making is a part, an understanding of
the accuracy required of an impression material is
essential (Wadhwani et al., 2005). A good impression
is critical for an accurately fitting restoration. Flaws
in the impressions will result in inaccuracies in
the casts. A small void in the impression caused
by trapping an air bubble on one of the occlusal
surfaces will result in a nodule on the occlusal table.
And then, it will lead to an inaccurate articulator
mounting, and the diagnostic data will be incorrect.
An accurate impression is critical to the attainment
of a precise fitting restoration (Eriksson et al.,
1998). This is one important factor that determines
33
the longevity of restoration. The first step toward

a successful outcome is the selection of the proper
impression material for the appropriate application.
Improper manipulation of impression material
can lead to any inaccuracy throughout the whole
procedure. Inaccuracies in the replication process
will ultimately have an adverse effect on the fit
and adaptation of the final restoration (Petrie et al.,
2003). The choice of impression material is an
important role in making the dental prosthesis.
the tray for retention of impression material.

Two types of elastomeric impression materials,
addition silicone, Aquasil (VPS) impression material
and condensation silicone, Zetaplus impression
material were used. All these materials, which were
commercially available and recommended for use
in making fixed partial denture impression, were
stored at manufacturers recommended temperatures
before use and were mixed at room temperature so
as to simulate their clinical use.
An acceptable impression must be an exact or

accurate record of all aspect of the prepared tooth
(Rosenstiel et al., 2001). If there is the discrepancy
or a larger gap between the margin of the seated
restoration and the corresponding preparation border
line, it will increase the risk for secondary damages
on the tooth.
Aquasil (VPS), addition silicone impression material

was mixed following the manufacturers instructions.
Equal lengths of Aquasil catalyst and base were
dispensed onto the mixing pad. Impression material
was mixed by using a stiff spatula and a stropping
action. It was spatulated for approximately 30-45
seconds of mixing time. To obtain optimum physical
properties, the impression was mixed completely
homogeneous (streak-free) at room temperature and
placed within the working time recommended by the
manufacturer. And then mixed impression materials
was loaded into the tray. After seating the tray, the
impression was held with finger pressure on the
stainless steel master die and took the impression.
The impressions were carefully removed from the
die after complete setting and examined any defects
and irregularities. Then, the impressions were rinsed
under running water and allowed to air dry. High
strength Type IV dental stone, GC Fuji-Rock, was
used while pouring the impression. Type IV gypsum
(Fuji-Rock) with a ratio of 20 ml of distilled water to
100 g of stone powder was hand-mixed for 1 minute.
The mixture was placed into the impression from
one end in small increments with a small instrument
until it completely filled the tray. While pouring, the
impression was kept on a vibrator to avoid any air
bubble entrapment. After 1 hour, the stone die was
separated from the impression and the measurements
of the reference lines were recorded and the mean
values were taken. This procedure was repeated ten
times for each stainless steel master die.
MATERIALS AND METODS

In this study, there was evaluated the dimensional
accuracy of two elastomeric impression materials on
two stainless steel master dies (die no: 1 and die no:
2). For each die, there were replicated ten times with
each impression material, therefore total number of
(40) stone dies were obtained.
Two circular standardized stainless steel dies were
milled to simulate the dimension of prepared teeth for
crowns. The dies were labeled 1 and 2. Stainless steel
die no: 1 has a diameter of (7.02) mm at the occlusal
surface, the height of (5.81) mm (occlusocervically)
and (90) shoulder margin. Stainless steel die no: 2
has a diameter of (6.11) mm at the occlusal surface,
the height of (5.69) mm (occlusocervically) and
(90) shoulder margin. Each die has tapering (6) and
(18) total occlusal convergence angles respectively.
Grooves were prepared on occlusal and proximal
surfaces of stainless steel dies as reference points for
taking measurements.
Before making the impression, the dies were
thoroughly cleaned to remove any residue and
contamination of the surface of the dies and allowed
to air dry. Each stainless steel die was taken the
impression by using perforated stainless steel
impression tray to provide as uniform thickness (2
mm) of impression material. Holes were made on
the surface of the stainless steel tray by straight
fissure bur of (2 mm) in diameter on the surface of
For the condensation silicone, Zetaplus impression

material was mixed according to the manufacturers
instructions. Equal strand lengths of base material and
activator were dispensed directly from the tubes on
a clean mixing pad according to the manufacturers
instruction and mixed with a clean stainless steel
34
spatula. And then mixed impression material was

loaded into the tray. The impression was seated to
the predetermined position and held with finger
pressure for an adequate amount of time to ensure
that setting reaction was complete before removal.
Since the reaction took place in room temperature,
which was lower than the mouth temperature, the
tray was held in place for a longer duration than the
manufacturers recommendation to ensure complete
polymerization. After that, the impression was
removed with straight pull directed along the path of
withdrawal of the dies. The impression was checked
and impression with voids and other inaccuracies
were discarded. After impression making, these
were rinsed under running water and allowed to
air dry. Then, type IV stone was poured into the
impression. After 1 hour, the stone die was separated
from the impression and the measurements of the
reference lines were recorded and the mean values
were taken. This procedure was repeated ten times
for each stainless steel master die.
A greater amount of discrepancies meant less

dimensional accuracy and a smaller amount
of discrepancies indicated greater dimensional
accuracy.
For determining the dimensional accuracy of the

impression materials, the dimensional comparison
between the stainless steel dies and the stone
dies were done. The dies were measured in two
dimensions; diameter and vertical height of the
stainless steel master dies were recorded. The mean
measurements of stone dies casted from different
impression materials were recorded and compared
with the measurements of stainless steel master dies.
And then diameter discrepancies, vertical height
discrepancies and percentage of deviations were
calculated.
The dimensional accuracy of impression materials

is one of the important factors for the fabrication
of the crown Both diameter and vertical height
discrepancies of stone dies reproduced from master
die 1 and master die 2 by using Aquasil impression
material were positive values, that meant there were
greater dimensions (both diameter and vertical
height) of stone dies than that of stainless steel
master dies by using Aquasil impression material.
RESULTS
Comparing the results of two different impression
materials, the mean values of diameter discrepancies
and percentage of deviations of the samples that
reproduced from master die 1 and master die
2 by using Zetaplus impression material were
significantly greater than that of Aquasil impression
material (p < 0.05).
The mean values of vertical height discrepancies
and percentage of deviations of the samples that
reproduced from master die 1 and master die
2 by using Zetaplus impression material were
significantly greater than that of Aquasil impression
material (p < 0.05).
DISCUSSION
For Zetaplus impression material, the diameter

discrepancies of stone dies reproduced from master
die 1 and master die 2 were positive values but vertical
height discrepancies of stone dies reproduced from
master die 1 and master die 2 were negative values.
That indicated that larger diameter of stone dies were
observed when compared with the stainless steel
master dies but there were smaller vertical height of
stone dies than that of stainless steel master dies by
using Zetaplus impression material.
Diameter Discrepancy = Diameter of stone die

Diameter of master die
Height Discrepancy = Height of stone die Height
of master die
The differences between the measurements of the
stone dies and the measurements of the master dies,
divided by the measurements of the master dies and
multiplied by 100 were expressed as percentage of
deviation from the master dies for each test group.
A positive change may be due to an overall contraction

and a negative change may be represented an
overall expansion of impression materials. But, the
dimensional alterations may not occur equally in all
directions (S et al., 2008).
The percentage of deviation= [(Measurement of

Stone Die - Measurement of Master Die) /
The polymerization shrinkage may be an important

factor influencing the dimensional accuracy. It is
Measurement of Master Die] x 100
35
well understood that, for polymerized materials, the

greater linear polymerization contraction resulting
greater dimensional changes. Increase in dimensions
may also be partially attributed to the impression
material shrinkage upon setting towards the tray or
by linear setting expansion of the die material.
working time, setting time, temperature, correct

manipulation of impression materials, material
volume and
uniform thickness of impression
material.
The impression making procedure is the basis
step towards a successful outcome. It is not only
important to select the proper impression material
but also need to minimize the possible procedure
errors in each and every step.
For Zetaplus impression material, the stone dies

wider in the horizontal aspect and shorter vertically.
During polymerization reaction, the impression
materials shrink towards the center of mass and then
redirect this shrinkage towards the impression tray
walls, resulting in image of the master die is larger
in diameter but shorter in height.
REFERENCE LISTS
Berg,J.C., Johnson,G.H. and Lepe,X., (2003).
Temperature effects on the rheological properties
of current polyether and polysiloxane impression
materials during setting. Journal of Prosthetic
Dentistry, 90: pp. 150-161.
CONCLUSION
Well-fitting indirect restorations can only be made
when there are accurate models of the oral tissues
available, made from high quality impressions.
A defective impression may lead to an inaccurate
model. Distortion of impression is a problem that is
inherent in all of the steps involved in fabricating an
indirect restoration and yield poor result.
Caputi,S. and Varvara,G., (2008). Dimensional

accuracy of resultant casts made by a monophase,
one-step and two-step, and a novel two-step putty/
light-body impression techinique: an in vitro study.
Journal of Prosthetic Dentistry, 99: pp. 274-281.
Ceyhan,J.A., Johnson, G.H. and Lepe,X., (2003).
The effect of tray selection, viscosity of impression
material, and sequence of pour on the accuracy of
dies made from dual-arch impressions. Journal of
Prosthetic Dentistry, 90: pp. 143-149.
Addition silicone and condensation silicone are

elastomeric impression materials widely used in
dentistry. Although silicones are considered to be
materials of the greatest accuracy and precision, they
are still subjected to some dimensional changes.
Chee,W.W.L. and Donovan,T.E., (1992). Polyvinyl

siloxane impression materials:A review of properties
and techniques. Journal of Prosthetic Dentistry, 68:
pp. 728-732.
According to the results obtained in this study

regarding linear dimensional changes of the resulting
stone dies, the following conclusion can be drawn:
Dimensional accuracy of addition silicone
impression material, Aquasil,was better than
condensation silicone impression material, Zetaplus.
Chen,S.Y., Liang,W.M. and Chen,F.N., (2004).

Factors affecting the accuracy of elastomeric
impression materials. Journal of Dentistry, 32(8):
pp. 603-609.
There was a statistically significant difference in

the dimensional accuracy between two impression
materials (p <0.05). ADA Specification Number
19 recommended a maximum negative change in
dimension of 0.5% after a minimum of 24 hr (Council
on Dental Materials and Devices, 1977). According
to the results of this study, percentage of deviation
(height) of the samples reproduced from master
die 2 (18 TOC angle) by using Aquasil impression
material were within the range of 0.18 to 0.73 (mean
0.441) and other results showed the dimensional
changes exceeded 0.5%. These dimensional changes
may depend on certain important factors such as
Combe, E.C. and Grant, A. A., (1992). Notes on

Dental Materials. Sixth Edition. pp. 115-126.
Eriksson,A., Ockert-Eriksson,G. and Lockowandt,P.,
(1998). Accuracy of irreversible hydrocolloids
(alginates) for fixed prosthodontics. A comparison
between irreversible hydrocolloid, reversible
hydrocolloid, and addition silicone for use in the
syringe-tray technique. European Journal of Oral
Science,106: pp. 651660.
Petrie,C.S., Walker,M.P., OMahony,A.M. and
Spencer,P., (2003). Dimensional accuracy and
36
surface detail reproduction of two hydrophilic vinyl

polysiloxane impression materials tested under dry,
moist, and wet conditions. Journal of Prosthetic
Dentistry, 90: pp. 365-372.
Wadhwani,C.P.K., Jhonson,G.H., Lepe,X. and

Raigrodski,A.J., (2005). Accuracy of newly
formulated fast-setting elastomeric impression
materials. Journal of Prosthetic Dentistry, 93:
pp.530-539.
Rosenstiel,S.F., Land, M.F. and Fujimoto,J., (2001).

Contemporary Fixed Prosthodontics. Third Edition.
pp. 354-377.
Table 1. The discrepancies and percentage of deviations calculated for the diameter of the samples
reproduced from master die 1 and master die 2
Diameter Discrepancy = Diameter of stone dieDiameter of master die
Aquasil
Diameter
Discrepancies
Serial No.
1
2
3
4
5
6
7
8
9
10
Zetaplus
Die 1
Die 2
0.22
0.20
0.20
0.21
0.20
0.20
0.20
0.20
0.19
0.20
0.07
0.08
0.12
0.10
0.11
0.11
0.12
0.09
0.09
0.07
Percentage of
Deviation
Die 1
3.13
2.85
2.85
2.99
2.85
2.85
2.85
2.85
2.71
2.85
Diameter
Discrepancies
Percentage of
Deviation
Die 2
Die 1
Die 2
Die 1
Die 2
1.15
1.31
1.96
1.64
1.80
1.80
1.96
1.47
1.47
1.15
0.48
0.48
0.46
0.38
0.41
0.38
0.29
0.19
0.20
0.19
0.12
0.10
0.13
0.13
0.12
0.13
0.10
0.09
0.09
0.13
6.84
6.84
6.55
5.41
5.84
5.41
4.13
2.71
2.85
2.71
1.96
1.64
2.13
2.13
1.96
2.13
1.64
1.47
1.47
2.13
Table 2. The results of statistical analysis made by using unpaired students t test for the diameter
discrepancies and percentage of deviations at a significant level of p=0.05
Master Die 1 group
Impression
Materials
Aquasil
Zetaplus
p value
Master Die 2 group
Discrepancies in
mm
(Mean SD)
Percentage of
Deviation
(MeanSD)
Discrepancies in
mm
(Mean SD)
Percentage of
Deviation
(MeanSD)
0.202
(0.0079)
0.346
(0.1195)
2.878
(0.1104)
4.929
(1.7007)
0.096
(0.019)
0.114
(0.0171)
1.571
(0.3082)
1.866
(0.2813)
0.001
0.001
0.039
0.038
37
Table 3. The discrepancies and percentage of deviations calculated for the vertical height of the samples
reproduced from master die 1 and master die 2
Height Discrepancy = Height of stone die Height of master die
Aquasil
Serial
No.
1
2
3
4
5
6
7
8
9
10
Height Discrepancies
Zetaplus
Height
Discrepancies
Percentage of Deviation
Percentage
of Deviation
Die 1
Die 2
Die1
Die2
Die 1
Die 2
Die1
Die 2
0.10
0.11
0.12
0.12
0.12
0.03
0.01
0.02
0.03
0.02
1.72
1.89
2.07
2.07
2.07
0.53
0.18
0.35
0.53
0.35
-0.48
-0.48
-0.21
-0.23
-0.17
-0.09
-0.10
-0.10
-0.08
-0.08
0.11
0.11
0.11
0.11
0.11
0.03
0.04
0.03
0.01
0.03
1.89
1.89
1.89
1.89
1.89
0.53
0.70
0.53
0.18
0.53
-0.16
-0.16
-0.16
-0.14
-0.14
-0.07
-0.07
-0.05
-0.03
-0.05
-8.26
-8.26
-3.61
-3.96
-2.93
-2.75
-1.58
-1.76
-1.76
-1.41
-1.41
-1.23
-2.75
-2.75
-2.41
-2.41
-1.23
-0.88
-0.53
-0.88
Table 4. The results of statistical analysis made by using unpaired students t test for the vertical height
discrepancies and percentage of deviations at a significant level of p=0.05
Master Die 1 group
Impression
Materials
Aquasil
Zetaplus
p value
Discrepancies in
mm
(Mean SD)
Master Die 2 group
Percentage of
Deviation
(MeanSD)
Discrepancies in
mm
(Mean SD)
Percentage of
Deviation
(MeanSD)
0.112
(0.0063)
-0.233
(0.1333)
1.927
(0.1118)
-4.009
(2.2934)
0.025
(0.0097)
-0.072
(0.0203)
0.441
(0.1698)
-1.267
(0.4042)
0.000
0.000
0.000
0.000
Figure 1. Diagram of Stainless Steel Die 1 and Stainless Steel Die 2
38
Figure 2. Aquasil impression material
Figure 3. Zetaplus impression material
Figure 4. Stone dies casted from Stainless steel die number: 1 by Aquasil impression material
39
Figure 5. Stone dies casted from Stainless steel die number: 1 by Zetaplus impression material
Figure 6. Stone dies casted from Stainless steel die number: 2 by Aquasil impression material
Figure 7. Stone dies casted from Stainless steel die number: 2 by Zetaplus impression material
40
Original Research
In vitro study of margical fit of ceramage

crown related to different margin designs
Yee Mon Shwe 1, Win Lwin 2, Myint Myint San 1
1
Department of Conservative Dentistry, University of Dental Medicine, Yangon, Myanmar
Department of Conservative Dentistry, University of Dental Medicine, Mandalay, Myanmar
ABSTRACT
INTRODUCTION
The objective of this study was to investigate

the effect of margin design on the marginal fit of
Ceramage (indirect resin composite) crown, by two
evaluation methods; evaluation in cemented crowns
and the evaluation in non-cemented crowns. Three
stainless steel dies with a total convergence of 6
and different margin designs (90 rounded shoulder,
chamfer and 110 sloped shoulder) were milled with
CNC (computer numerical control) machine. For
evaluation in cemented crowns, a total of 54 crowns
(18 for each design) were fabricated. The crowns
were seated onto the stone dies and cemented with
Glass Ionomer Cement. Each cemented crown was
then longitudinally sectioned into equal halves.
SEM (Scanning Electron Microscope) at 100 x
magnification was used to evaluate the marginal fit
of test specimens. For evaluation in non-cemented
crowns, 30 crowns (10 for each design) were made
on the stone dies. Marginal gaps were evaluated
on their respective steel dies at 40 x magnification
using USB (Universal Serial Bus) microscope.
In cemented crowns, mean values were: 70.43
30.36 m in chamfer, 65.43 25.79 m in shoulder
and 59.17 20.91 m in sloped shoulder. In noncemented crowns, the means were: 58.19 21.84 m,
46.99 34.9 m and 43.8717.38 m in chamfer,
shoulder and 110 sloped shoulder respectively.
One-way ANOVA analysis showed that there was no
statistically significant difference in marginal gaps
of three margin designs in both evaluation methods.
Nowadays, major concern about esthetic dentistry

leads to development of metal free, tooth colored
restorative materials, such as high strength porcelain
and new generation indirect resin composite
materials. The second-generation indirect composites
have microhybrid fillers with a diameter of 0.041
m, which is in contrast to that of the first-generation
composites that were microfilled. The filler content
is also twice that of the organic matrix content in the
second-generation indirect composites.
Ceramage (Shofu, Japan) is a micro ceramic
composite system with a filler content of 73% (PFSProgressive Fine Structured fillers and nano hybrid
fillers) supported by an organic polymer matrix.
The filler is mainly zirconium silicate and resin
matrix contains urethane type. Metal-free polymer
crowns have the benefit of requiring less axial tooth
reduction than all ceramic or metal-ceramic crowns
(Rammelsberg et.al., 2005). With the advancement in
resin cement, the bond between the resin composite
crown and resin cement would probably be effective
in obtaining better marginal seal.
Accuracy of fit is accepted as a very important factor
when fabricating a full veneer crown. Among the
different margin designs for full dental crown, 1.2
1.5 mm wide shoulder or deep chamfer finish line
can be used for composite crowns (Rosenstiel et.al.,
2001). Gap measurements at margin are frequently
used to quantify fit (Groten and coworkers, 2000).
Two common methods used to measure the
marginal gap are measurement of marginal gaps
after cementation of the crowns, and measurement
of marginal gap of non- cemented crowns along the
Key words: Indirect resin composite, Marginal gap,

Marginal opening, Full veneer crown
41
circumference of the crown/tooth interface.
Measurement of marginal gap in non- cemented

crowns with USB microscope
This study was to test whether the marginal fitness

of Ceramage crown is within satisfactory range and
to assess the role of margin design (radial or rounded
shoulder, chamfer and 110 sloped shoulder) on
marginal fit. This assessment was done by two
evaluation methods (evaluation in cemented crowns
and evaluation in non-cemented crowns). The null
hypothesis stated was that different margin designs
of Ceramage crown would not influence the marginal
fit of the full veneer crown whether cemented or not.
Each of 30 (10 for each margin) crowns was fixed

on their respective steel dies with the aid of a device;
G clamp to prevent movement during measurement.
USB (universal serial bus) microscope at 40 x
magnification with the image analyzing software
(MicroCapture software) was used for marginal
gaps measurement. Four diametrical opposing
points had been chosen in the samples for the
readings of the marginal gap. In each one of the
points, five measurements had been carried through
and the total of 20 accomplished measurements per
crown was achieved. The mean of these 20 values
were taken as a mean of each crown. Means and
standard deviations were calculated for each group.
Gap distance was defined as the perpendicular
measurement from the most cervical extent of the
crown to the most cervical extent of finishing line
(Absolute marginal opening (AMO)- according to
Holmes, 1989) (Figure 3).
MATERIALS AND METHODS

Three stainless steel dies were fabricated by milling
with computer numerical control (CNC) machine.
Each die had the following dimension. 9 mm in
diameter at cervical area, 6.37 mm in diameter at
occlusal surface and 6 mm from occlusal surface to
the cervical end of the preparation. All dies had total
occlusal convergence angle of 6 degree (Figure 1).
1.3 mm width of groove was placed on the occlusal
surface of each die for orientation of the crowns.
Each die had 1 mm width of different margin designs
(90 degree shoulder with rounded internal line angle,
chamfer and 110 degree sloped shoulder).
Measurement of marginal gap in cemented

crowns with SEM
The 54 (18 for each margin) crowns were cemented
to the stone dies with type I Glass Ionomer Cement
(GIC). During cementation, constant defined load
was applied onto the die with axially directed load
applying device (Figure 4). Cementation force
was set at 213 Newton (48 lb) for 4 minutes. Each
cemented crown was then sectioned through the
center of the crown perpendicular to its longitudinal
axis into equal halves with a diamond disc. One
section was then polished and examined under
SEM (JEOL, JSM- 5610, Tokyo,Japan) at 100
magnifications to measure the marginal gap of the
crowns (Figure 5).
Impressions of dies were made using medium

bodied, addition silicone impression material
(Aquasil Monophase, Dentsply International,USA)
with custom acrylic tray. For evaluation in cemented
crowns, a total of 54 (18 impressions per system
of steel die) were made. For evaluation in noncemented crowns, a total of 30 (10 impressions per
system of steel die) were made. Impressions were
then poured with type dental stone (Fuji Rock,
GC, Dentsply, USA) and 84 model dies were made.
Next, Ceramage composite crowns were made
according to the manufacturers recommendation.
Polymerizations of Ceramage composite were
performed in light-curing unit; Solidilite V (Shofu,
Kyoto, Japan) (Figure 2). All crowns were fabricated
with the same dimension by using a silicone index.
The fabrication of all full veneer crowns was
performed by the same operator.
The marginal gap (marginal opening, MO) of each

crown was evaluated by measuring the vertical
perpendicular distance from the internal surface of
the crown margin to the prepared cervical margin of
the die (Figure 6). The measurements for each crown
were carried out at two points, at labial and lingual
margins. The mean of these two values was taken
as a mean of each crown. Data were analyzed with
one way analysis of the variance (ANOVA) by using
SPSS 16 software. The level of significance was
established at 0.05.
The marginal gaps were evaluated with two

evaluation methods (evaluation in non-cemented
crowns and in cemented crowns) by using USB
microscope and SEM respectively.
42
Results
shoulder margin may be greater than that of chamfer,

the configuration of shoulder margin design favors
the more precise adaptation of composite to the
marginal area and over adaptation is unlikely when
compared to chamfer margin. This may be the
cause of lower marginal gap in shoulder than that of
chamfer. The study of Cho et.al. (2004) concluded
that rounded shoulder provide the better marginal
fit than chamfer margin. They claimed that clear
marginal defects of the shoulder finish line could
be detected more easily than the defects in the other
finish lines. Thus, adding composite material to the
marginal defects can be done more frequently.
The mean values and standard deviations of the

marginal gaps recorded for all groups are listed in
tables 1 and 3 and shown graphically in Fig. 7. One
way ANOVA results are presented in tables 2 and 4
and these results shows that there was no statistically
significant difference (P > 0.05) in different margin
designs. Therefore three different margin designs
do not significantly affect the overall marginal
adaptation of Ceramage crown in both evaluation
methods.
DISCUSSION
The marginal openings between 100 and 200 m
are considered clinically acceptable with regard
to longevity despite theoretical requirements of
cementation films between 25 and 40 m (Boening
et.al., 2000). McLean and von Fraunhofer (1971)
stated that marginal gap as high as 120 m is
considered clinically acceptable. Based on these
findings, crowns fabricated with Ceramage indirect
resin composite system demonstrated clinically
acceptable range of marginal adaptation in general
and well below maximum acceptable value after
cementation.
For cast metal crown, the more the restoration

margin ends with an acute angle, the shorter the
distance between the restoration margin and the tooth
(Schillinburg et.al.,1997). For composite crowns,
acute margin design of 110 margin had the lowest
values in both methods, but the difference was not
statistically significant. In cemented crowns with
SEM evaluation method, the type of margin did not
influence marginal adaptation after cementation. All
these margin configurations likely allow for similar
escape of the luting agents tested.
Some studies on composite crowns (Akbar
et.al.,2006 and Tsitrou et.al.,2007) revealed that
the finish line design had no influence on marginal
adaptation, while others (Cho et.al.,2004) reported
that shoulder type of preparation provide the better
marginal fit than chamfer margin designs. The
dissimilarity of the results of the researches may be
because of variation in the mateials and methods
used in various investigators studying marginal fit.
Different methods that quantify marginal fit include measurement of sectioned specimens, measurement
of specimens or their replica by direct visualization,
measurement of the replica of the marginal gap
(replica technique), tactile examination using
an explorer, and radiographs (Ayad et.al.,2009).
Among these techniques, measurement of sectioned
specimens of cemented crowns and measurement of
specimens by direct visualization in non- cemented
crowns are commonly used methods.
In present study, the marginal gaps of different margin

designs (chamfer, 90 rounded shoulder, 110 sloped
shoulder) were not significantly different in both
evaluation methods. Both methods have found to
prove that cervical preparation for Ceramage crown
with chamfer, 90 shoulder of 110 sloped shoulder
would not affect on marginal gap formation.
One of the inherent properties of polymer-based
materials is shrinkage during polymerization (Kim
and Watts, 2004). Polymerization shrinkage around
margin is probably major reason for marginal
discrepancies. It is stated that Ceramage composite
exhibit about 2.5 vol % of polymerization shrinkage.
The lack of bonding to periphery permitted
almost unrestricted three-dimensional volumetric
shrinkage of the resin composite. The greater the
circumferential composite thickness at the margin
may cause the greater shrinkage at the margin. The
amount of polymerization shrinkage at the margin is
corresponding to the amount of gap formation at the
margins.
Measurement of sectioned specimen requires

cementation of the crown. The hydraulic back
pressure of the cement can increase the marginal
gap. So the film thickness of cement can be one of
In the current study ,even though the area at the

43
the confounding variables affecting the marginal

fit. The evaluation of sectioned crown limits the
number of measurement per specimen. However,
the configurations of the margin design were well
revealed in cross-sectioned view. In addition,
overcontour or undercontour of the crown margin
did not affect the marginal gap evaluation and
measurement. Moreover, this method permits an
accurate focus of marginal gap on crown-tooth
restoration interface.
under microscope because it is believed that when

cementing them, the precision of primary adaptation
is lost and the influence of the cement type, viscosity
and luting techniques and seating force become
preponderant (Hilgert et.al. , 2004). The direct view
method using the USB microscope is considered
convenient, accurate, easy and rapid for determining
the marginal gap distance.
There were some limitations in this study. (1) The
CNC prepared steel die was used instead of the
natural tooth. However these dies could provide
standardizing the preparation dimension. Another
limitation is that, (2) different measuring devices
were used in each method. SEM imaging system is
used in many researches of marginal fit evaluation
because of its high accuracy. On the other hand,
USB microscope with image analyzing software is
the easier way of marginal gap measurement. Hence,
both devices can be used to measure marginal
discrepancies. (3)All retainers were produced and
tested under ideal conditions, which might not
reflect the precision in clinical use.
SEM imaging provided the images of high resolution

and could show the fine destination of cement-crown
interface and cement-die interface. In this method,
marginal opening (MO) - the vertical perpendicular
distance from the internal surface of the crown
margin to the prepared cervical margin of the die
was measured. SEM evaluation on sectioned die
needs to fix a crown to die with cement. Although
cementation might influence marginal gap, the
variation could be reduced by standardization of
cementation procedure.
In another evaluation method, luting agent was not
used and marginal gaps were measured directly
along the circumference of the margin at the crown/
tooth interface. This technique has the advantage of
being noninvasive, convenient, accurate, easy and
rapid for determining the marginal gap distance.
However, it is difficult to repeat the measurements
from an identical angle and to distinguish the real
marginal gap from its projection (Martnez-Rus
et.al., 2011). The measurement in this method is the
measurement from the most cervical extent of the
crown to the most cervical extent of finishing line;
absolute marginal discrepancy or absolute marginal
opening (AMO). Therefore, reference points used in
measurement are different in both methods.
Within the limitation of this study, it is noticed that

the marginal fit of indirect composite (Ceramage)
crowns were not influenced by the different margin
designs. This could be attributed to small difference
in polymerization shrinkage of composite resin due
to similar composite thickness occupied at three
marginal sites.
CONCLUSION
Within the limitations of this in vitro study, the
conclusion can be drawn that(1) There was no statistically significant difference
in marginal gap between chamfer, 90 rounded
shoulder and 110 sloped shoulder margin design.
However, AMO might vary significantly depending

on the over-extension or under-extension of the
crowns. The margins of the crown and die may seem
to be sharp clinically, but appear rounded when
microscopically viewed. It is difficult to select a
point where the marginal opening is to be measured.
Therefore, in this study not only AMO but also MO
was measured in order to evaluate the marginal gaps
of Ceramage crowns in different situations.
(2) The mean marginal gaps of resin composite

(Ceramage) crowns with different margin designs
were within the range of clinical acceptance (less
than 120 m).
(3) Although results of both methods are similar,
evaluation in non-cemented crowns is easy and
rapid in addition to being non-destructive unlike
evaluation in cemented crowns.
Some investigators prefer the gap measurement

of non-cemented crown by direct evaluation
44
REFERENCES
G.,Schmitter,M.,(2005).Clinical performance of
metal-free polymer crowns after 3 years in service. J
Dent, 33: pp.517-523.
Akbar, J.H., Petrie, C.S., Walker, M.P., Williams, K.

and Eick, J.D., (2006). Marginal adaptation of Cerec
3 CAD/CAM composite crowns using two different
finish line preparation designs. J Prosthodont, 15:
pp.155-163.
Rosenstiel, S.F., Land, M.F. and Fujimoto, J., (2001).

Contemporary Fixed Prosthodontics. Third Edition.
Mosby Inc, Missouri,U.S.A.
Ayad, M.F., (2009). Effects of tooth preparation

burs and luting cement types on the marginal fit of
extracoronal restorations. J Prosthetic Dentistry, 18:
pp.145151.
Shillingburg, H.T., Hobo, S., Whitsett, L.D., Jacobi,

R. and Brackett, S.E., (1997). Fundamental of
Fixed Prosthodontics, Third Edition, Quintessence
Publishing Co, Inc, Carol Stream.
Boening, K,W., Wolf, B.H., Sehmidt ,A.E., Kastner

,K. and Walter ,M.H., (2000). Clinical fit of procera
allceram crowns. J Prosthet Dent, 84(4): pp.419424.
Tsitrou, A., Northeast ,S.E. and van Noort, R.,

(2007). Evaluation of the marginal fit of three
margin designs of resin composite crowns using
CAD/CAM. Journal of Dentistry, 35 (1): pp.68-73.
Cho, L.R., Choi, J.M., Yi, Y.J. and Park, C.J.,

(2004). Effect of finish line on marginal accuracy
and fracture strength of ceramic optimized polymer
/ fiber reinforced composite crowns. J Prosthet
Dent, 91(6): pp.554-559.
Groten, M., Axmann, D., Probster, L. and Weber, H.,
(2000).Determination of the minimum number of
marginal gap measurements required for practical in
vitro testing , J Prosthetic Dentistry , 83(1): pp.4049.
Hilgert, E., Buso, L., Neisser , M.P. and Bottino,
M.A., (2004). Evaluation of marginal adaptation of
ceramic crowns depending on the marginal design
and the addition of ceramic. Braz J Oral Sci , 3(11).
pp.619-623.
Holmes, J.R, Bayne, S.C., Holland, G.A. and Sulik,
W.D., (1989). Considerations in measurement of
marginal fit. J Prosthet dent, 62: pp.405-408.
Kim, S.H. and Watts, D.C., (2004). Polymerization
shrinkage-strain kinetics of temporary crown and
bridge materials. Dental Materials, 20:pp.8895.
Martnez-Rus, F., Mara, J.S., Begoa, R. and
Prades, G., (2011). Evaluation of the absolute
marginal discrepancy of zirconia-based ceramic
copings. J Prosthet Dent, 105: pp.108-114.
McLean, J.W. and von Fraunhofer, J.A., (1971) . The
estimation of cement film thickness by an in vivo
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R a m m e l s b e r g , P. , S p i e g l , K . , E i c k e m e y e r ,
45
Figure 1. Schematic presentation for preparation

design of stainless steel die with shoulder, chamfer
and 110 sloped shoulder margin
Figure 6. Points of measurement of the marginal gap

in different marginal situations ( in cemented crown)
Figure 2. Ceramage composite materials and light

curing unit (Solidite V)
Table (1) Means and standard deviations of marginal

gaps in three different margin designs (in cemented
crowns)

Figure 3. Points of measurement of the marginal
gap (in non-cemented crown)
Margin
design
number
Mean (m)
Standard
deviation
(m)
90 rounded
shoulder
18
65.43
25.79
18
70.43
30.36
18
59.17
20.91
54
65.01
25.90
Chamfer
110 sloped
shoulder
Total
Table (2). Results of one way ANOVA test for

marginal gaps of three different margin designs (in
cemented crowns)
Figure 4. Load applying device used in cementation
Sum of
Squares
Degree
of
freedom
Mean
Square
F
ratio
p
value
.849
.434
Between
Groups
1145.342
572.671
Within
Groups
34420.462
51
674.911
35565.804
53
Total
Table (3) Means and standard deviations of marginal

gaps in three margin designs (in non-cemented
crowns)
Figure 5. SEM Photomicrograph (x 100) of

marginal gap at 90 rounded shoulder margin
46
Margin design
Number
Mean (m)
SD (m)
90rounded
shoulder
10
46.99
34.90
Chamfer
10
58.19
21.84
110sloped
shoulder
10
43.87
17.38
Total
30
49.68
25.67
Table (4) Results of one way ANOVA test for

marginal gaps of three different margin designs (in
non-cemented crowns)
Sum of
Squares
Degree
of
freedom
Mean
Square
F ratio
0.851734
0.437
Between
Groups
1134.06
567.0301
Within
Groups
17974.88
27
665.7364
Total
19108.94
29
Figure (7) Marginal gaps in three groups of margin

design (Cemented vs Non-Cemented crowns
according to different evaluation methods)
Marginal gaps in cemented crowns
Marginal gaps in non-cemented crowns
47
Case Report
A case report of Superior Ankyloglossia

Soe Khaing Thet Suu1, Khin Maung1, Sun Sun Win2
1
Oral and maxillofacial surgical ward, (1000) Bedded Naypyitaw General Hospital, Department of Health
Department of Pediatric Dentistry, University of Dental Medicine (Yangon), Department of Medical Science
Abstract
palate and associated limb abnormalities (Bolling et

al., 2007). Superior ankyloglossia presents as part
of aglossy-adactylly syndrome, Hanhart syndrome
and oro-facio-digital syndrome (Kothari and Gupta,
2005).
A congenital abnormality (birth defect) is an

abnormality in body structure or function that is
present at birth. Ankyloglossia, also known as
tongue-tie is not uncommon birth defect in orofacial structure, in which abnormal shortness of the
frenum resulting in limitation of its movements.
If it is functionally accepted, not all the cases
of ankyloglossia need to be treated surgically. A
5-days old infant was referred to Oral and maxillafacial surgical Department, of Naypyitaw Hospital,
with a complaint of tongue fused to the palate.
The attachment of tongue to the palate, which is
known as superior ankyloglossia is a rare anomaly.
Functional limitation presenting with superior
ankyloglosssia is difficulty in feeding because of
limitation of tongue movement and cannot perform
suckling action. Before surgical separation of
tongue from palate, patient supportive care was
done in co-operation with Pediatric Department
of Naypyitaw Hospital. Patients development and
medical condition had been assessed by consultant
pediatrician and whether the infant can be operated
under general anesthesia was assessed by consultant
anaesthesiologist. By co-operation of surgeon,
pediatrician and anesthesiologist, the patient had
operation done at the age of 5 months successfully,
without any complications. A team work approach
brought a successful outcome in this rare case of
superior ankyloglossia.
Case report
A five-day old male infant, born on 26th May 2012
was referred to oral and maxillofacial surgical ward
of (1000) Bedded Naypyitaw General Hospital from
Taungoo General Hospital with chief compliant of
congenital anomaly in tongue. By history taking, it
was known that he was delivered at Swa Hospital of
Yedashe Township in Bago Division, as emergency
LSCS, and weighed 2.7 kg at birth. There was no
congenital anomaly in family and the 28-year old
mother already had had a normal child.
On clinical examination, there was abnormal
attachment of the tongue tip to anterior part of palate
about 5-7 mm (fig-1), and the patient also seems to
have slight micrognathic appearance (Fig-2).
Fig-1 photograph showing abnormal adhesion of
tongue tip to palate
Keyword: Superior ankyloglossia

Introduction
Superior ankyloglossia (or) Ankyloglossum
superius is rare congenital craniofacial condition
characterized by tongue tip adherence to the hard
48
Management
Fig-2 photograph showing slight micrognathic

appearance
Supportive care
Since the infant had attached tongue to the palate,
limitation of tongue movement was present and
cannot perform suckling action. Consultation with
pediatrician was urgently done for feeding problem,
and supportive care.
To find out if the patient had other congenital
anomalies or not and for supportive care, the infant
had been transferred out to the Child ward of (1000)
Bedded Naypyitaw Hospital. He had given test
feeding of 50cc/3hrly through naso-gastric tube from
that day onwards. Necessary investigations were
made by pediatrician and no signs and symptoms
of syndromic condition were found. When the
patient was nine days old, he was referred back to
OMFS ward for further management of superior
ankyloglossia.
Abnormality was also noted at upper limbs; absence

of finger nails and abnormal shortening in right
index, middle and ring fingers (Fig-3), and in left
index finger (fig-4).
Fig-3 photograph showing right hand
Oral and maxillofacial management

Operation had been planned at the childs age of
3 months and older. Follow up was done monthly
both by pediatrician and surgeon. Meanwhile, the
child had practiced spoon feeding very well. At the
age of 3 months and body weight became 4kg, he
was admitted to OMFS ward for operation. When
anaesthetic assessment was done, it was found that
he had chest infection and operation had postponed
until there is no chest infection.
Pediatrician gave him antibiotics of Amoxicillin 4ml
(125mg/5ml) 8hrly for one week and follow up was
done by Child ward. One month later he was again
admitted to OMFS ward, and necessary assessments
were done. When anaesthesiologist and pediatrician
recommended that the child was fit for surgery,
operation was performed on 17th October 2012 as
elective surgery.
Fig- 4 photograph showing left hand
Although there was limitation of mandibular

movement, oro-endotracheal tube intubation
was successfully performed by anaesthesiologist
(Associate Professor Dr. Daw Mu Mu Naing).
To get minimal haemorrhage and post-operative
anaesthesia, 2% lignocaine with 1:100,000 adrenalin
(1.8ml) was injected to the tip of the tongue, and
separation of tongue-palate was done by using
cautery. Incised wound of tongue was sutured with
49
4/0 vicryl until there was no bleeding.

Post-operative management
For infection control, antibiotics (Blumox-P
125mg 8hrly) was given for a week, and for pain
management, analgesics of paracetamol 125mg was
given 8hrly for 5 days. Spoon feeding was allowed
after 2 hours operation.
During first and second post-operative days, the
child had fever (99.6 F- 101 F). But no feeding
problem and bleeding was seen. From third postoperative day onwards, no fever and he went back
home on 22nd October 2012 (5th post-operative day).
Follow up
The patient was recalled after one week for follow
up review. There was no compliant or complications
present. After that, it was done regular follow up
monthly.
Conclusion
By co-operation of surgeon, pediatrician and
anesthesiologist, the patient had operation done
at the age of 5 months successfully, without any
complications. A team work approach brought a
successful outcome in this rare case of superior
ankyloglossia.
References
Bolling R.P., Sabeeh V., Stewart J.M.Jr, Newsome.
R.E., Moses
M.H., Ankyloglossum Superius
syndrome : diagnosis and surgical management. J
Craniofac surg. 2007, 18(5):1094-7.
Kothari P.R., Gupta A., ankyloglossia superior.
Indian Pediatrics 2005, 42: 1249.
50
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Myanmar Dental Journal - Vol. 22, No.

Myanmar Dental Journal - Vol. 22, No. 1, January 2015

Impact of periodontal diseases on Systemic Health..........................................................................4

Original Research Articles

Role Of Human Papillomavirus (HPV) And Its Detection In Potentially

Malignant Disorders And Oral Squamous Cell Carcinomas.............................................................9

Epidemiological and Clinico-pathological study of 120 cases .......................................................13

of Oral Cancers in Myanmar 2012

A new peripheral tracing material for mandibular complete denture impression............................17

Effect of mixing methods and disinfection on dimensional accuracy of ........................................21

An in vitro study on coronal microleakage of endodontic acess cavity using ...............................27

single seal and double seal techniques

A comparative study on the dimensional accuracy of two types of ................................................33

elastomeric impression materials

A case report of Superior Ankyloglossia.........................................................................................48

Myanmar Dental Journal - Vol. 22, No. 1, January 2015

Fight against Oral Cancer

Professor Swe Swe Win

Myanmar Dental Journal - Vol. 22, No. 1, January 2015

Impact of periodontal diseases on

Department of Periodontics, Sharavathi Dental College and Hospital, Shivamogga, India

Systemic Health has been accepted by the medical

A plethora of Systemic diseases have effect on Oral

The aim of this paper is to provide a birds eye-view

The gingival crevice forms an ideal niche for the

Key words: Periodontal disease, Periodontal

Myanmar Dental Journal - Vol. 22, No. 1, January 2015

products enter the systemic circulation through

field of research in Microbiology and immunology

Focal Infection theory Revisited:

Effects of oral diseases on remote sites1,2:

The focal infection theory put forth in 1900s by

Numerous cross-sectional and longitudinal studies

or cheilosis6. Diabetes alters the oral ecoflora, with

The American diabetes Association has included

Recently, it has been suggested that Diabetes and

The effects of Diabetes Mellitus on oral tissues

Myanmar Dental Journal - Vol. 22, No. 1, January 2015

patients who received periodontal therapy exhibited

provided beneficial results. Many studies since,

There is an increase in the viscosity of blood and

Another condition of serious concern or rather

Porphyromonas gingivalis and Streptococcus sanguis

Myanmar Dental Journal - Vol. 22, No. 1, January 2015

bacterial strains can cause platelet aggregation

1. Mealey BL. Influence of periodontal infections

POSSIBLE EFFECTS ON RESPIRATORY

2. Page RC. The pathobiology of periodontal

Much research is needed in this field to shed light

3. Seymour GJ, Ford PJ, Cullinan MP, Leishman S,

EFFECT ON MEN HEALTH:

5. DAiuto D, Parkar M, Andreou G, Suvan J, Brett

A recent research has found that levels of PSA, or

6. Aldridge JP, Lester V, Watts TL, Collins A, Viberti

7. Christgan M, Pallitzsch KD, Schmalz G, Kreiner

8. Grossi SG, Skrepcinski FB, DeCaro T, Robertson

Numerous literature reviews and an equal number

9. Andrews WW, Hauth JC, Goldenberg RL.

Myanmar Dental Journal - Vol. 22, No. 1, January 2015