Sulaimani dental journal vol1 issue1 2014

زان'كۆی س'لێمانی
Sulaimani Dental Journal
ISSN:(2309C4656
Scientific(Journal(Published(by(University(of(Sulaimani(
School(of(Dentistry
Volume(1(((Issue(1((((2014
SDJ

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To the spirit of
Professor Dr. Nazar G. Talabani (1948-2013)
Scientific Publication of the University of Sulaimani
School of Dentistry
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Scientific Publication of the School of Dentistry / University of Sulaimani
Editor'(in('Chief(Emeritus(
Dr.!Falah!A.!Hawrami! !
Editor('in('Chief(
Dr.!Ibrahim!S.!Gataa! !
Associate(Editor(
Dr.!Abdulsalam!AL7Zahawi! !
SDJ
Managing(Editor(
Dr.!Anwar!A.!Amin! !!
Editorial)Board)
Professor'Sauza'A.'Faraj'
Professor'Salam'Al2Qaisi'
Professor'Balkees'T.'Gareeb'
Assist.'Professor'Shanaz'M.'Gaffor'
Assist.'Professor'Saeed'A.'Lateef'
Assist.'Professor'Fadil'A.'Kareem'
Assist.'Professor'Aras'M.'Rauf'
''
Advisory)Editorial)Board)) !
''Professor'Richard'van'Noort'''''(UK)''
''Professor'Salem'Al'Samaray''''(Iraq)'''''''''''''''''
''Professor'Ali'Alzubaidi'''''''''(Iraq)''''''''''''''''''''''''''''''''''
''Professor'Anwar'Tappuni'''''(UK)''''''''''''''''''''''''''''''''''''
''Professor'Hussain'F.'Al2Huwaizi'''(Iraq)''
Assist.'Professor'Adil'Alkayat'''(Iraq)'
Assist.'Professor''Zeewar'Al2Qassab'''(Iraq)''
Assist.'Professor'Qais'H.'Musa'''('Iraq)'
Assist.'Professor'Intesar'J.'Mohammed'(Iraq)'
Assist.'Professor'Lamia'H.'AL'Nakib''(Iraq) !
'''
Editorial)Of1ice))
Dr.'Mohammed'Abdalla'
Dr.Tara'A.'Rasheed''
Dr.'Arass'J.'Noori'
Dr.Dler'A.'Khursheed'
Dr.'Ranjdar'M.'Talabani' !
Journal)Secretory))
Kaniaw'A.'Babala

Editorial!
Dear colleagues, I would like to take this opportunity to express my thanks and
gratitude to everyone who contributed to issue Sulaimani Dental Journal
that will be a platform, scientifically and culturally, which serves the
educational and academic process in the school of dentistry.
I call on all researchers in the field of dentistry, employees of dental colleges
and technical institutes to send their research and contribute to the
dissemination of this journal. We will be so pleased to receive any comments or
suggestions form you about the process of issuing or processing the journal and
the articles published in it.
Also the editorial board invites the postgraduate students to send their
research for the purposes of publishing and they will find great cooperation in
this area.
The first issue of the Journal of the School of Dentistry is an important
progress which will be followed by other steps that lead to develop sound
scientific bases regarding the mission of our school in the field of dentistry.
We must point out that the publishing of this journal came from numerous
efforts of colleagues and do not forget the great role of the professor Nazar
Talabani whose inspiration for the determination of his ideas and orientations
for the issuance of the journal.
Finally I would like to thank the editorial staff and designers to bring out the
journal in this way.
!
!
Editor in Chief

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Mason$ J.$ Concepts$ in$ dental$ public$ health.$
Philadelphia:$Lippincott$Williams$&$Wilkins;$2005.$
Chapter'in'a'Book:'
Alexander$ RG.$ Considerations$ in$ creating$ a$
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p.$187B210.$
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Author’s*summarized*check*list*
1. Cover*letter
2. Title*page
3. Abstract*
4. Introduction*
5. Material*and***methods
6. Results
7. Discussion
8. Conclusion
9. References
10. Acknowledgments*
11. Figures*
12. Tablets*
13. Copyright
14. Confect*of*Interest**

Table of Contents
Contents Page
I The use of maxillary first molar as forensic aid in racial and sexual
dimorphism of Kurdish population in Sulaimani city.
Azhar Ghanim Ahmed
1
II Prevalence of oral mucosal changes among 6- 13-year old children in
Sulaimani city, Iraq.
Shokhan Ahmed Hussein & Arass Jalal Noori
5
III Comparison of volume loss of tooth structure between traditional and
conservative FPD designs.
Abdulsalam Al-Zahawi, E .Tsitrou & Richard van Noort
10
IV Assessment of oral hygiene in a sample of orthodontically treated patients
using different bracket materials with different motivational techniques in
Sulaimani City.
Aras M. Rauf, Tara A. Rashid, Ara O. Fatah, Fadil A. Kareem & Nyaz O. Mohammad
15
V Evaluation of microleakage in the gingival margin of class II resin
composite restoration when using three placement techniques (An in vitro
study).
Miwan S. Abdul-Rahman
21
VI The prevalence of fracture in acrylic removable dentures in Sulaimani
city.
Cheman A. AL-Jmoor
29
VII Prevalence of common white lesions in oral cavity among patients
attended School of Dentistry in Sulaimani/ Iraq.
Akeel Saeed Abd-Sada
35
VIII Focal epithelial hyperplasia in Yemeni families: Three case reports.
Salwa M. Al- Shaikhani
39
IX Management of impacted permanent maxillary incisors caused by
supernumerary tooth: Case report.
Anwar A. Amin & Zhwan J. Rashid
42

Sulaimani Dent. J. 2014; 1:1-4 Ahmed
The'use'of'maxillary'first'molar'as'forensic''
aid'in'racial'and'sexual'dimorphism'of''
Kurdish'popula9on'in'Sulaimani'city
Azhar Ghanim Ahmed*
SDJ
Sulaimani'Dental'Journal
Abstract
Objectives: To find out the utility of using permanent maxillary first molar as a forensic tool for sex determination, and to
compare tooth size for both side in the same sex in Kurdish people.
Materials and methods: The study sample comprised 120 casts of Kurdish peoples (67 females and 53 males) from
Sulaimani city - Iraq, with age ranging from 13-33 years. The bucco-lingual (B-L) and mesio-distal (M-D) linear
measurements of the maxillary first molars were calculated using digital vernier calipers. Percentage of sexual dimorphism
was calculated.
Results: The mean values of B-L and M-D parameters were greater in males than females and greater on right side
compared to with left side. The mean values of B-L parameters showed statistically significant differences between males
and females with p ˂0.05.The differences in B-L and M-D parameters between the right and the left side were statistically
significant in males.
Sexual dimorphism amounted to 3.48%, 2.83% for the right and left bucco-lingual diameter respectively as compared to
1%, 0.91 % for right and left mesio-distal diameters of the maxillary first molars respectively.
Conclusion: The result of the study showed that the bucco-lingual diameters of permanent maxillary first molars
exhibiting significant sexual dimorphism in Kurdish sample and can be used as adjunct in sex determination.
Keywords: Maxillary first molar, sexual dimorphism, forensic
Received: September 2013, Accepted: January 2014
!
Introduction
Teeth are known to be unique organs made of the
most enduring mineralized tissues in the human
body (1). Teeth, being the hardest and chemically
the most stable tissue in the body are an excellent
material in living and non-living populations for
anthropological, genetic, odontologic and forensic
investigations (2).
Variation in tooth size is influenced by genetic
and environmental factors. Several studies have
reported tooth size variation between and within
different racial groups(3).
Sexual dimorphism refers to those differences
in size, stature and appearance between male and
female that can be applied to dental identification
because no two mouths are alike (4).
Sex assessment of skeletal remains is an
important step in building the biological profile of
unidentified skeletons recovered in forensic
contexts. It enables a more focused search of
missing person files, with the potential of
recovering antemortem records for comparison
and establishing identity. This will decrease
getting the number of wanted individuals to a
probability of (50%), which can results in a more
accurate way of identifying the person sought.
The sexual difference in the human skeleton has
been well studied in many populations (5).
Numerous studies show that the tooth size
standards based on odontometric investigations
are population specific and can be used in age and
sex determination (6). Sex determination using
dental features is primarily based upon the
comparison of tooth dimensions in males and
females or upon the comparison of frequencies of
non-metric dental traits like Carabelli’s trait of
upper molars, deflecting wrinkle of the lower first
molars, distal accessory ridge of the upper and
lower canines or shoveling of the upper central
incisors (7). In metric analysis, apart from
mandibular canine, maxillary central incisors and
maxillary first molar exhibit sexual dimorphism.
Being early in eruption and less impacted when
compared to mandibular canine, maxillary first
molar serve as a good odontometric tool(8). Mesio-distal
(M-D) and bucco-lingual (B-L) diameters of
the permanent tooth crown are the two most
commonly used and researched features used in
determining sex on the basis of dental
measurements ( 9).
The aims of study are to find out the utility of
using permanent maxillary first molar as a
forensic tool for sex determination, and to
compare tooth size for both side in the same sex
in Kurdish people. !!
*Assist.'Lecturer'in'Dept.'of'Oral'Diagnosis6'School'of'Den9stry,'Faculty'of'Medical'Sciences,'University'of'Sulaimani.'
'Author'contact:'azhar7ortho@yahoo.com'

Materials and methods ! The study sample includes 120 casts of Kurdish
population from Sulaimani city of Iraq with age
ranging from 13-33 years who attended the dental
clinic for orthodontics treatment, or night guard
appliances construction (private dental clinic and
dental clinic of school of dentistry of Sulaimani
University). The research has been accepted and
approved by the ethical committee of Faculty of
Medical Sciences, University of Sulaimani.
The inclusion criteria were; casts with the
presence of bilateral maxillary first molars, intact
mesiodistal and bucco-lingual surfaces of the
crown, not affected by any attrition, caries lesions,
restorations, proximal stripping, or serious health
problems.
The measurements include:
1. Bucco-lingual measurement (B-L) of the
maxillary first molars on the study cast on
either sides of upper jaw using digital vernier
of resolution 0.01 mm. This measurement is
the greatest distance between both buccal
and lingual surfaces of crown of tooth
estimate. Figures (1).
2. Mesio-distal (M-D) measurement between
the contact points of maxillary first molars,
on either side of upper jaw using the same
digital vernier. This measurement is the
largest mesiodistal dimension(3,4). Figures
(2).
All measurements were performed by a single
examiner to eliminate intra-observer error; the
descriptive statistics calculate (mean and standard
deviation), and analysis significant (t-test) were
performed using the SPSS 16 for Windows, the
level of statistical significance set up at p<0.05.
The sexual dimorphism (the percent by which
the tooth size of males exceeds that of females)
(10). are calculate following this equation:
Percentage of sexual dimorphism = [(Xm/
Xf)-1] x 100
Where Xm = mean male tooth dimension; Xf
= mean female tooth dimension. !
Results
From table (1), the present study showed that the
mean values of B-L and M-D for both right and
left sides parameters were greater in males than
females; also the mean values of B-L and M-D
parameters were greater in the right side for both
sexes in comparing with their left side. The
comparison of mean values of B-L parameters
showed statistically significant differences
between males and females but non-significant
differences of sexual dimorphism in right and left
sides on mean values of M-D diameters.
The present study showed significant
differences in B-L and M-D parameters between
the right and the left side in males, where as there
K2
!
Fig. 1. Fig.%1. 'BB6-LL'd dimimeennsssiioonn' eess9timmaattee
Table(1):Mean'values'of'linear'measurements'for'B6L'and'M6D'dimensions'of'maxillary'first'molar'in'both'sexes'
at'both'sides'and'percentage''of'sexual'dimorphism'.
Trim Side Gender No. Mean/(mm) S.D t4value P4value %Sexual/dimorphism
Bucco4lingual Right Male 53 11.55 0.619 3.74 0* 3.48
Female 67 11.16 0.488
Le^ Male 53 11.46 0.611 3.01 0.003 2.83
Female 67 11.15 0.517
Mesio4distal Right Male 53 10.54 0.522 1.09 0.278 1
Female 67 10.43 0.528
Le^ Male 53 10.49 0.536 0.98 0.328 0.9
Female 67 10.39 0.511
Fig.%2.%M6D'dimenssion'es9mate
*P6value'is'significant'at'p'˂'0.05;'S.D'is'the'standard'devia9on;'No.'is'the'number'

was non- significant differences in females, table
(2).
The sexual dimorphism in this study
accounted to 3.48%, 2.83% for the right and left
B-L diameter respectively, as compared to 1%,
0.91 % for right and left M-D diameter of the
same teeth. !
Discussion
Several studies (11-18) revealed that mean values of
B-L and M-D parameters were greater in male
than female, that agree with the present study;
this difference in dimensions of the teeth can be
attributed to sex chromosomes that are known to
cause different effects on tooth size. The 'Y'
chromosome influences the timing and rate of
body development, thus producing slower male
maturation, and acts additively and to a greater
extent than the 'X' chromosome (19); while other
study indicated to the difference in size has been
attributed to differently balanced, hormonal
production between the sexes consequent to the
differentiation of either male or female gonads
dur ing the s ixt h or s event h we e k of
embryogenesis rather than any direct effect of sex
chromosome themselves (20).
When comparing both sides, mean values of
B-L and M-D parameters were greater on the right
side, these results were in agreement with
previous studies (17,18,19) while these results were
in disagreement with Sonika et al(4) and
Zarringhalam M (21) who found that dimensions of
all permanent teeth were greater on the left side
than the right side in upper jaw.
The right-left differences may be attributed to
dental asymmetry; as perfectly bilateral body
symmetry is a theoretical concept that seldom
exists in the living organisms (4),this came in
agreement with the result of the present study
which revealed the differences in B-L and M-D
parameters between the right and the left side
were statistically significant in males.
The mean values of B-L and M-D parameters
on the right and the left sides of upper first molars
in both sex of Kurdish population were greater
than other previous population studies(Haryana
population in India,Croatians population and
Urhobos population in Nigeria) (4,7,18), in addition
to that Mahmood concluded Kurdish males and
females had larger tooth size and dental arch
dimensions in comparison to their Arabic
counterpart (22).
Statistically, this study is in agreement with
those reported in other population groups (4,5,17,18)
that showed significant of sexual dimorphism in
right and left sides of mean values of B-L
diameter of upper first molars, but discordances
with those of Croatians population in Vodanovic
et al study (7) that showed statistically significant
with upper canine only; also sexual dimorphism
in left and right sides for mean values of M-D
diameters for the last study showed no statistically
significant, this agree statistically results with
Kurdish population in Sulaimani sample in the
present study, and disagree with Sonika et al (4)
and Narang R et al (17) while Deo (18) showed no
statistically significant on M-D width of left side
and statistically significant on the right side.
The percentages of sexual dimorphism of
Kurdish people differed in comparing with other
population as in Urhobos people in Nigeria that
showed sexual dimorphism for M-D wide and B-L
wide of maxillary first molar were3.0% in all
parameters except left maxillary mesio-distal
width (1.0%) (18) while in Haryana population in
Indian Sexual dimorphism amounted to 5.44%
and 5.54% for right and left bucco-lingual
dimensions of maxillary first molars respectively
as compared to 4.74% and 4.84% for right and
left mesiodistal dimensions of the same teeth
measured on study casts (4). !
Conclusion
The study showed the bucco-lingual (B-L)
diameters of the maxillary first molars exhibiting
K3
Table'(2)':'Comparison'of'mean'values'of'B6L'and'M6D'parameters'between'the'right'and'the'le^'side'for'each'
sex.
Sex No. Parameter Side Mean(mm) S.D t4value p4value
Male 53 Bucco6lingual Right 11.55 0.619 4.69 0*
Le^ 11.46 0.611
Mesio6distal Right 10.54 0.522 2.13 0.038
Le^ 10.49 0.536
Female 67 Bucco6lingual Right 11.16 0.488 0.63 0.529
Le^ 11.15 0.517
Mesio6distal Right 10.43 0.528 1.73 0.089
Le^ 10.39 0.511
*P6value'is'significant'at'p'˂'0.05;'S.D'is'the'standard'devia9on;'No.'is'the'number'

significant sexual dimorphism in Kurdish people
and can be used as adjunct in sex determination.
The study also showed significant differences in
B-L and M-D parameters between the right and
the left side in males. !
References
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4. Sonika V, Harshaminder K, Madhushankari G.S,
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Haryana population (India). J Forensic
Odontostomatol. 2011; 29:37-43.
5. Sittiporn R, Suda R, Montip T, Peerapong S. Sex
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measurements.Oral Maxillofacial path J. 2013;
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7. Vodanovic M, Demo Z, Njemirovskij V, Keros J,
Brkic H. Odontometrics a useful method for sex
determination in an archaeological skeletal
population. J. of Archaeological Sci. 2007;
34:905-13.
8. Girija K, Ambika M. Permanent maxillary first
molars: Role in gender determination
(Morphometric analysis). J. Forensic Dent Sci.
2012; 4: 101-102.
9. Işcan MY, Kedici PS. Sexual variation in bucco-lingual
dimensions in Turkish dentition. Forensic
Sci Int. 2003; 137:160-64.
10. Rani P, Mahima VG, Pati K . Bucco-lingual
dimension of teeth- An aid in sex determination. J
Forensic Dent Sci .2009; 1:88-92.
11. Perzigian AJ. The dentition of the Indian Knoll
skeletal population: odontometrics and cup
number. Am J Phys Anthropol. 1976; 44:113-21.
12. Ghose LJ, Baghdady V. Analysis of the Iraqi
dentition: mesiodistal crown diameters of
permanent teeth. J Dent Res.1979; 58:1047-54.
13. Stroud JL, Buschang PH, Goaz PW. Sexual
dimorphism in mesiodistal dentin and enamel
thickness. Dentomaxillofac Radiol. 1994;
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14. Hattab FN, Al-Khateeb S, Sultan I. Mesiodistal
crown diameters of permanent teeth in
Jordanians. Arch Oral Biol. 1996; 41:641-5.
15. Rai B, Dhattarwal SK, Anand SC. Sex
determination from tooth. Medico-legal update
2008; 8:3-5.
16. Ghodosi A, Mosharraf R, Nia FF. Sexual variation
in bucco-lingual dimensions in Iranian dentition.
Inter J Dental Anthropol.2008; 12:1-7.
17. Narang R, Manchanda A , Arora P , Kaur G.
Sexual dimorphism in permanent 1st molar: a
forensic tool. Indian J Comp Dent Care. 2012. 2 :
224-227.
18. Deo E. A dimorphic study of maxillary first molar
crown dimensions of urhobos in Abraka, South-
Southern Nigeria. J. Morphol. Sci. 2012, 29:
96-100.
19. Acharya BA, Mainali S. Univariate sex
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Forensic Sci Inter. 2007; 173:47-56.
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mandibular canines and inter-canine arch widths
among males and females. Dissertation submitted
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21. Zarringhalam M. A comparison on the mesiodistal
width of right and left side teeth in people with
normal occlusion. J Dent Med. 2004; 17:5-11.
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Rafidain Dent J. 2012; 12: 71-79.
K4

Sulaimani Dent. J. 2014; 1:5-9 Hussein & Noori
Prevalence)of)oral)mucosal)changes)among)
6D)13Dyear)old)children)in)Sulaimani)city,)Iraq
Shokhan Ahmed Husseina
Arass Jalal Noorib
SDJ
Sulaimani)Dental)Journal
Abstract
Objectives: Understanding the distribution, etiology and epidemiology of oral mucosal changes is essential for preventive
and treatment planning. The aim of this study was to determine the prevalence and distribution of oral mucosal lesions and
normal variations among 6- to 13-year old children in Sulaimani city, north of Iraq.
Method: A cross-sectional survey was carried out on primary school students in Sulaimani city. A total of 5113 Kurdish
children was examined; 2757 (53.92%) were males and 2356 (46.08%) were females, enrolled in 20 primary public
schools. Any oral mucosal changes observed at the time of examination were recorded.
Results: The prevalence of oral mucosal changes was found to be 12.87% (658 children): 12.91% (356) males and 12.82%
(302) females, with no statistically significant gender variations (P>0.05). Twelve different oral mucosal changes/lesions
were diagnosed and the most common were herpes labialis (3.2%), aphthous ulcers (2.25%), linea alba (1.72%), angular
cheilitis (1.7%), traumatic ulcers (1.58%) and geographical tongue (1.33%). No statistically significant association was
found between different types of lesions and gender (P>0.05). The lips were found to be the most common affected site
(27.36%) followed by buccal mucosa (23.86%), tongue (18.54%), labial mucosa (14.13%), and the lip commissures
(13.22%).
Conclusion: The present study represents the first cross-sectional epidemiological study of the prevalence and distribution
of oral mucosal lesions among Kurdish Iraqi children in Sulaimani city providing the baseline data for future relative
preventive and health service programs.
Keywords: Oral mucosal lesion, Sulaimani city, oral health.
Received: October 2013, Accepted: January 2014
!
Introduction
While diagnosis of the wide variety of mucosal
lesions, which occur in the oral cavity, is an
essential part of dental practice, there are
relatively few systematic studies of the prevalence
of such lesions in children and youths. This is a
critical deficiency since appropriate diagnosis and
treatment requires knowledge of the relative
frequency or probability of possible lesions (1).
Epidemiological studies have showed a wide
variability in prevalence rates of oral lesions in
different age groups in populations. It has been
reported that diseases of the oral mucosa may
affect 25–50% of individuals, depending on the
population studied (2).
Despite World Health Organization (1980)
recommendations (3) to encourage more
epidemiological assessment of oral mucosal
lesions, the volume of literature in this area is
much more limited than that on other oral
conditions such as dental caries and periodontal
diseases (4) and a limited information is available
on oral mucosal conditions in Iraqi population
(5,6).As the variability is quite high, there is a need
of data concerning the prevalence rates of oral
mucosal lesions in specific populations to develop
a rational oral health policy (7).
The aim of the this study was to investigate
the prevalence of oral lesions among 6 to 13-year
old Kurdish children in Sulaimani city, and a
potential relationship between gender and the
occurrence of these lesions.
!
Methods
Sulaimani City is located in the north east of Iraq
and the majority of the population is of Kurdish
origin. After achieving research approval from the
Ethical Committee of the Faculty of Medical
Sciences and the Scientific Committee of the
School of Dentistry/ University of Sulaimani,
proper authorities and primary school administers,
aDepartment)of)Oral)Diagnosis.)School)of)Den5stry/)University)of)Sulaimani.)(shokhan.hussein@univsul.net))
bDepartment)of))Pedodon5cs,)Orthodon5cs,)and)Preven5ve)Den5stry.)School)of)Den5stry/)University)of)Sulaimani.

a cross-sectional survey was carried out on
Kurdish primary school children aged between 6
to 13-years old.
Calculation of the sample size was based upon
an expected oral mucosal lesion prevalence of
25% (2,7) with a precision of 0.05 and a confidence
level (CI) of 99%. Twenty primary schools were
randomly selected from different geographical
parts of the city center for our survey and the total
sample number reached 5113 children of Kurdish
ethnicity, which satisfied our sample size
requirement. For oral lesions with recurrent
behavior, if observed, a questionnaire was sent to
the parents of those children to clarify the medical
history of their children. Periapical swellings and
fistula due to dental caries and periodontal
diseases were not included in this study.
The World Health Organization (1980) clinical
criteria recommendations were followed for
recording of oral soft tissue lesions (3) depending
on visual examinations only. All children were
examined in their schools by the same examiner.
A special medical case recording chart was
prepared for the data collection. Data analysis was
performed using the SPSS software program
(Version 16.0, SSPS Inc, Chicago, Ill, USA). The
chi square test was used for the data analysis.
Statistical significance (P value) was calculated as
follows: P>0.05 as non significant and P<0.05 as
significant.
!
Results
A total of 5113 children were examined in this
study: 2757 (53.92%) males and 2356 (46.08%)
females. The prevalence of oral mucosal lesions
was found to be 12.87% (658 children): 12.91%
(356) males and 12.82% (302) females.
Statistically there was no association between
prevalence of oral mucosal lesions and gender
(Table 1).
Table 2 shows the distribution of different
types of oral mucosal lesions according to the
gender. Twelve different mucosal lesions were
diagnosed, of which the most commonly found
were herpes labialis (3.32%), aphthous ulcers
(2.25%), linea alba (1.72%), angular cheilitis
(1.7%) , t r auma t i c ul c e r s (1.58%) and
geographical tongue (1.33%).
Herpes labialis, linea alba, angular cheilitis,
geographical tongue and traumatic ulcers were
found to be more common in males, whiles
aphthous ulcers and fissured tongue were more
common in females. However, statistically there
was no association between the type of the lesion
and gender of the child (P > 0.05) (Table 2).
The lips (including the vermilions) were found
to be the most common affected site for oral
mucosal lesion occurrence (27.36%) followed by
buccal mucosa (23.86%), tongue (18.54%), labial
mucosa (14.13%), and lip commissures (13.22%),
(Figure 1).
!
Discussion
Previous studies showed different prevalence
rates in children in different countries and among
different ethnic groups. There are no previous
Iraqi studies considering oral mucosal lesion in
children. Therefore, other global studies are
considered for comparison. A cross-sectional
survey among 13 to 16-year old students in Duzce
(Turkey) reported a 26.2% prevalence for oral
mucosal lesions (7) and a 28% prevalence of oral
lesions and normal variations of oral mucosa was
reported in a study on 12 to 15-year-old students
in Tehran (Iran) (8), while a 10.26% prevalence
was reported among children and youths aged
between 2 to 17-years old in USA (9). A cross-sectional
study on the oral mucosal conditions
among Indians from central Amazonia, Brazil
revealed that 52.57% of the children up to 12
years old and 73.44% of patients aged 13 years or
older presented at least one oral mucosal
J6
Table)1:)Sample)distribu5on)and)prevalence)of)oral)mucosal)lesions)by)gender.
Existence)of)Lesions
Gender
Yes No Total
Chi)Square)Test
No. % No. % No. %
Male 356 12.91% 2401 87.09% 2757 53.92% N.S*
Female 302 12.82% 2054 87.18% 2356 46.08%
Total 658 12.87% 4455 87.13% 5113 100%
*)P>0.05:)Not)significant)(N.S)

Table)2:)Distribu5on)of)different)types)of)oral)mucosal)lesions)in)children)by)gender.
Type)of)the)lesion
condition (10). Recent epidemiological studies
have shown a wide variability in the prevalence of
oral mucosal lesions in different regions of the
world and have led researchers to draw disparate
conclusions (11).
The prevalence of oral mucosal lesions in the
present study of primary school children aged
6-13-years old was 12.87% with no statistically
significant gender variations. Although no
statistically significant gender variation was
found, males (12.91%) showed more prevalence
than females (12.82%). Such findings are also
reported in other studies (7,9).
The lips, tongue and buccal mucosa were
found to be the most common sites for oral
mucosal lesion occurrence and this result agrees
with previous studies (12). The most common
lesions found were herpes labialis, aphthous
ulcers, linea alba, angular cheilitis, traumatic
u l c e r s a n d g e o g r a p h i c a l t o n g u e . Th e
epidemiological literature relating to oral mucosal
lesions in children and adolescents is mostly
related to oral mucosal lesions such as oral
ulceration, herpes labialis and other mucosal
alterations which are of interest because of the
absence of a clear understanding of their aetiology
and relationship to other conditions (13).
Herpes labialis was found to be the most
common lesion (3.32%) in this study and its close
to similar findings by other studies (7,14), while
differs from some studies (1,15). Herpes labialis is
the reactivation of the primary infection, often
following a prodromal period, and lesions present
early on as clusters of vesicles on the lip which
soon burst and scab over (13).
It has been estimated that a third of school-age
children have a history of recurrent aphthous
stomatitis(16). One or more small ulcer may occur
at frequent intervals and the majority of aphthous
ulcers in children are of a minor variety, usually
healing within 2 weeks. The major type is rarer,
affecting one in 10 patients with recurrent
aphthous stomatitis. It normally has its onset after
puberty and it is chronic, with ulceration lasting
several weeks (17).
Prevalence of aphthous stomatitis was 2.25%
and slightly more prevalent in females than males.
This figure is close to a prevalence rates reported
from Spain (18). However, slightly lower rates
reported from Brazil (1,10) and USA (4), and higher
prevalence rates were reported from Slovenia (19).
With respect to gender, there appears to be no
clear predilection for one sex or the other (10). As
was found in our study, some studies found a
slightly higher susceptibility of aphthous
stomatitis in females (11).
Linea alba was found to be the third most
common lesion in our study with a prevalence rate
J7
*)P>0.05:)Not)significant)(N.S)
Gender
Male Female Total Chi)Square)Test
No. % No. % No. %
Herpes)labialis 92 3.34 78 3.31 170 3.32 N.S*
Aphthous)ulcer 58 2.1 57 2.42 115 2.25 N.S
Linea)alba 48 1.74 40 1.7 88 1.72 N.S
Angular)cheli5s 49 1.78 38 1.61 87 1.7 N.S
Fissured)tongue 17 0.62 15 0.64 32 0.63 N.S
Trauma5c)ulcer 45 1.63 36 1.53 81 1.58 N.S
Geographic)tongue 37 1.34 31 1.32 68 1.33 N.S
Fordyce)spots 7 0.25 5 0.21 12 0.23 N.S
Mucocele 1 0.04 1 0.04 2 0.04 D
Strawberry)tongue 1 0.04 0 0 1 0.02 D
Fibroma 1 0.04 0 0 1 0.02 D
Median)rhomboid)glossi5s 0 0 1 0.04 1 0.02 D

of 1.72%. However, Jahanbani et al, reported
linea alba as the most common finding among
adolescent students from Tehran(8), while Parlak et
al. reported it to be the second most common
lesion in Turkish adolescents (7).
Although the prevalence rate of angular
cheilitis (1.7%) was lower than results found by
some studies reported from South Africa (20), Iran
(8) and Turkey (7), but it is in accordance with other
studies reported from North America (9), Southern
India (21), Argentina (14) and Slovenia(19). Although
our study did not explore the etiological factors
for angular cheilitis, but nutritional deficiencies
and anemia are among the proposed causative
factors that should be considered when observing
children with such lesions (7,8).
Traumatic ulcers on the lips, tongue, labial and
buccal mucosa accounted for 1.58% of the
lesions. Such ulcers are usually due to trauma
from external injuries (e.g. falls during playing) or
caused by lip and tongue biting or from a sharp
edge of a carious tooth causing frictional ulcers.
Kleinman et al. (4) reported a prevalence rate of
0.09% for traumatic ulcers among North
American children and youth while and Shulman
(9) found that cheek/ lip bites (1.89%) were the
most prevalent lesions in a different study and
these results are comparable to our study and they
are from national epidemiological surveys.
However, other studies (10,18) provide different
prevalence rates for traumatic ulcers and such
differences may be due to different sample
selection. There is an association between the
occurrence of all traumatic lesions and age, with a
reduction in their prevalence with increasing age.
A traumatic ulcer rapidly heals within a few days
after elimination of the causal agent, confirming
its traumatic origin and therefore its diagnosis (11).
Epidemiological studies have shown a high
frequency of tongue diseases among mucosal
lesions of the oral cavity, although the prevalence
varies in different parts of the world (11,22). Most
frequently occurring conditions are fissured and
geographic tongue (22). This variability is
produced by differences in the race, sex and age
of samples and by the use of different diagnostic
criteria, methodologies and procedures by
different researchers(22).
Geographic tongue (benign migratory
glossitis) is more common in girls and the
condition has no known cause, although it has
been associated with allergies in children(12).
However, Furlanetto et al.(13) reviewed 18 papers
about geographical tongue and found great
variations in the prevalence rate, which ranged
from 0.2% to 14.3%. Also stated that “the average
prevalence in most studies is low, which could
indicate that this lesion is not seen very often in
children” (13). The occurrence of fissured tongue
varies between 0.6 and 15.7%, rising to 25–50%
in some studies and a connection between the
occurrence of geographic tongue and fissured
tongue been suggested by some authors (22).
The prevalence of geographic tongue in the
present study was 1.33% of all children examined
with no statistically significant gender variation
and this figure is close to those prevalence rates
reported by some studies from South Africa 1.6%
(37) and USA (American Caucasian students)
1.41% (23), while differ from other studies (6,24).
Such differences may be related to the difference
in sample selection and the diagnostic criteria
J8
!
Figure)1:)Distribu5on)of)oral)mucosal)lesions)according)to)the)loca5on)in)the)oral)cavity.

employed and this difference is also present in the
prevalence rate of fissured tongue which was only
0.63%.
!
Conclusion
The present study represents the first
epidemiological cross-sectional study of
prevalence and distribution of different oral
mucosal lesions and normal variations in Iraq and
in particularly among Kurdish Iraqi 6 to 13-year
old children in Sulaimani city.
Further epidemiological studies are
recommended for younger children and
adolescents among the Kurdish population for
future relative preventive and health service
programs.
!
References
1. Bessa CFN, Santos PJB, Aguiar MCF, do Carmo
MA V. Prevalence of oral mucosal alterations in
children from 0 to 12 years old. J Oral Pathol
Med. 2004;33:17–22.
2. Andreasen JO, Pindborg JJ, Hjörting-Hansen E,
Axéll T. Oral health care: more than caries and
periodontal disease. A survey of epidemiological
studies on oral disease. Int Dent J. 1986;36:207–
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3. Kramer IR, Pindborg JJ, Bezroukov V, Infirri JS.
Guide to epidemiology and diagnosis of oral
mucosal diseases and conditions. Community Dent
Oral Epidemiol. 1980;8:1–24.
4. Kleinman D V, Swango PA, Pindborg JJ.
Epidemiology of oral mucosal lesions in United
States schoolchildren: 1986-87. Community Dent
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5. Gaphor SM. Developmental oral anomalies
among school children. Iraqi Dent J. 1999;24:77–
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6. Ghose LJ, Baghdady VS. Prevalence of
geographic and plicated tongue in 6090 Iraqi
schoolchildren. Community Dent Oral Epidemiol.
1982;10:214–6.
7. Parlak a H, Koybasi S, Yavuz T, Yesildal N, Anul
H, Aydogan I, et al. Prevalence of oral lesions in
13- to 16-year-old students in Duzce, Turkey. Oral
Dis. 2006;12:553–8.
8. Jahanbani J, Morse DE, Alinejad H. Prevalence of
oral lesions and normal variants of the oral
mucosa in 12 to 15-year-old students in Tehran,
Iran. Arch Iran Med. 2012;15:142–5.
9. Shulman JD. Prevalence of oral mucosal lesions in
children and youths in the USA. Int J Paediatr
Dent. 2005;15:89–97.
10. Dos Santos PJBJB, Bessa CFN, de Aguiar
MCFCF, do Carmo MAV. Cross-sectional study of
oral mucosal conditions among a central
Amazonian Indian community, Brazil. J Oral
Pathol Med. 2004;33:7–12.
11. Rioboo-Crespo M del R, Planells-del Pozo P,
Rioboo-García R. Epidemiology of the most
common oral mucosal diseases in children. Med
Oral Patol Oral Cir Bucal. 2005;10:376–87.
12. Delaney JE, Keels MA. Pediatric oral pathology.
Soft tissue and periodontal conditions. Pediatr
Clin North Am. 2000;47:1125–47.
13. Furlanetto DLC, Crighton A, Topping GV a.
Differences in methodologies of measuring the
prevalence of oral mucosal lesions in children and
adolescents. Int J Paediatr Dent. 2006;16:31–9.
14. Crivelli MR, Aguas S, Adler I, Quarracino C,
Bazerque P. Influence of socioeconomic status on
oral mucosa lesion prevalence in schoolchildren.
Community Dent Oral Epidemiol. 1988;16:58–60.
15. Spicher VM, Bouvier P, Schlegel-Haueter SE,
Morabia A, Siegrist CA. Epidemiology of herpes
simplex virus in children by detection of specific
antibodies in saliva. Pediatr Infect Dis J.
2001;20:265–72.
16. Flaitz CM, Baker KA. Treatment approaches to
common symptomatic oral lesions in children.
Dent Clin North Am. 2000 ;44:671–96.
17. Field EA, Brookes V, Tyldesley WR. Recurrent
aphthous ulceration in children--a review. Int J
Paediatr Dent. 1992 ;2:1–10.
18. Garcia-Pola MJ, Garcia-Martin JM, Gonzalez-
Garcia M. Prevalence of oral lesions in the 6-
year-old pediatric population of Oviedo (Spain).
Med oral. 2002;7:184–91.
19. Kovac-Kovacic M, Skaleric U. The prevalence of
oral mucosal lesions in a population in Ljubljana,
Slovenia. J Oral Pathol Med. 2000;29:331–5.
20. Arendorf TM, van der Ross R. Oral soft tissue
lesions in a black pre-school South African
population. Community Dent. Oral Epidemiol.
1996;24:296–7.
21. Mathew AL AL, Pai KKM, Sholapurkar AA,
Vengal M. The prevalence of oral mucosal lesions
in patients visiting a dental school in Southern
India. Indian J Dent Res.2008;19:59–61.
22. o r o s-Balog T, Vincze N, a n o czy J, Vörös-Balog
T, Bánóczy J, Voros-Balog T, et al. Prevalence of
tongue lesions in Hungarian children. Oral Dis.
2003;9:84–7.
23. Redman RS, Vance FL, Gorlin RJ, Peagler FD,
Meskin LH. Psychological component in the
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J9

Sulaimani Dent. J. 2014; 1:10-14 Al-Zahawi et al
Comparison"of"volume"loss"of"tooth"structure"
between"tradi*onal"and"conserva*ve"FPD"designs
Abdulsalam Al-Zahawia, E .Tsitroub, Richard van Noortb
Sulaimani"Dental"Journal
Abstract
Objectives: The purpose of this study is to evaluate the amount of tooth structure that is sacrificed with the conventional
preparation of a 3-unit bridge and compare this with a variety of more conservative 3-unit bridge designs.
Materials and methods: Fifty typodont Frasaco teeth were used to prepare five 3-unit FPD preparation designs (25 lower
right first premolar teeth and 25 lower right first molar teeth). One conventional full coverage crown retainer, two different
innovative partial coverage crown retainer and two different Inlay design retainer. The volume of tooth structure lost was
measured for each design and statistically analyzed.
Results: One-way ANOVA with Tukey’s test statistical analysis of the results at (p˂ 0.001), revealed that there was a
highly significant effect of the preparation design on the volume loss of tooth structure. Volume tooth structure saved
design IV and V was about twice that saved with the partial coverage crown in design II and III.
Conclusion: The amount of tooth structure sacrificed in the proposed conservative FPD designs is significantly less than
that calculated for the traditional design.
Keywords: Bridge design, Conservative, Resin bonded ceramic, Tooth structure.
Received: September 2013, Accepted: January 2014
!
Introduction
Natural tooth morphology has a robust relation to
original needs. The wide occlusal table of
posterior teeth needs to withstand a maximum
occlusal bite force of up to 750 N during
maximum intercuspation and preserve tooth
vitality (1-3).
The introduction of an all-ceramic FPD as an
alternative to metal-ceramic FPD exhibits an
exceptional aesthetic appearance and a high level
of biological compatibility (4). However, their
brittleness required an adequate amount of tooth
structure to be removed, to provide enough space
to be occupied by restoration thickness that can
withstand the occlusal bite forces. This has an
impact on the loss of tooth structure, vitality and
strength of the abutment tooth. The introduction
of resin bonded ceramic, has facilitated
innovative, conservative preparation designs for
single crown and FPD restorations (5).
Conservation of tooth structure can be
maintained by decreasing the cutting depth and
surface area that can potentially preserve more
enamel structure, which will enhance the bond
strength of resin-bonded restorations (6-9).
Adherence to the minimal preparation design
guidelines and using self-limiting burs for
preparation prevents both over-reduction and
under-reduction that may compromise the results
(10). Introduction of small-diameter non-cross-cutting
burs and non-concentric hand pieces help
to reduce over cutting of tooth structure during
preparation (8).
Tooth structure loss messured by weiged the
tooth or scanned using a laser profilometer and
the volume of remaining tooth structure calculated
before preparation and after preparation (9,11).
The purpose of this study is to evaluate the
volume of tooth structure that is sacrificed with
the conventional preparation of a 3-unit bridge
and compare this to a variety of more
conservative 3-unit bridge designs.
!
Materials and Methods
I. Preparation of the abutment teeth
Fifty typodont Frasaco teeth were used for this
study consisting of five teeth in each group (25
lower right first premolar teeth and 25 lower right
first molar teeth).
a"Conserva*ve"department,"School"of"Den*stry,"University"of""Sulaimani."(sazahawi@yahoo.com)."
b"Academic"Unit"of"Restora*ve"Den*stry,"School"of"Clinical"Den*stry,"University"of"Sheffield.
SDJ

All the teeth had been weighed before
preparation and 24 hours after preparation under
dry conditions by using air pressure and a high
Precision balance (Kern, d= 0.001g Kern and
Sohn GMBH, Baliongen, Germany) as shown in
Figure 1. Five 3-unit FPD preparation designs
were applied according to the Ivoclar Vivadent
Company guidelines for preparation of posterior
teeth to receive resin bonded all ceramic IPS
e.max restorations (12-13) and the preparation
guidelines for each group are given in Table 1 and
Table 2.
Each set of teeth was fixed on a Frasaco
standard working lower jaw model A-3 (GMBH,
Tettnang, Germany). The socket of the lower
second premolar was blocked with wax. A high
speed handpiece and contra angle handpiece
Figure"1:"Precision"balance,"d=0.001g
(W&H, Burmoss, Austria) were used for the
preparation with a cooling water jet. A new set of
diamond burs was used for every 10 abutment
tooth preparations. A paralleling device (Nesor
product LTD, Britain) was used during the
Figure"2:"Paralleling"device
preparation to enhance reproducibility of the
preparations as shown in Figure 2. The primary
preparation for designs I, II, III were started by
cutting three guiding grooves following the tooth
contour on each surface. The depth of guiding
grooves was 1.5 mm on the occlusal surface and 1
mm on the buccal, lingual and proximal wall
adjacent to the edentulous area. The grooves were
joined together with diamond burs (847RH 016,
Meisinger, Germany). The depth of the
preparation on the occlusal surface was controlled
using guide depth bur (828G, FG, 314, L 1.5 mm,
Meisinger, Germany) and a periodontal pocket
measuring probe (Williams probe). For the axial
wall, a tapered bur was used (847RH 016,
Meisinger, Germany). The convergence angle of
the wall was prepared to be ≈ 6º.
The inlay cavity was prepared by cutting the
central groove to prepare the occlusal cavity and
then the proximal box by bur (838G 014, L 4.0
mm, Meisinger, Germany). A butt joint margin
was prepared for the inlay cavity without bevels.
The buccal and lingual walls were tapered to
!11
Table"1:"Prepara*on"guidelines"for"FPD"design"I,"II,"and"III
Full&and&par=al&crown&
retained&FPD&designs
Occlusal&reduc=on&
in&mm
Axial&wall&reduc=on&
in&mm Finishing&line Convergence&angle
Design"I,"II,"and"III
1.5
1.2T1.5
Deep"rounded"
shoulder"I"mm 6°
Table"2:"Prepara*on"guidelines"for"FPD"design"IV"and"V
Inlay&retained&FPD&
designs
Pulpal&depth&in&mm Gingival&floor&depth&in&
mm
Width&buccal&–lingual&
in&mm
Divergence&angle
Design"IV"molar"tooth"
MO"inlay 1.5T2.0 1 4 6°
Design"IV"and"V"box"
inlay
4 1 4 6°

I II III
IV V
Figure"3:"Prepared"abutments"teeth"I)"tradi*onal"full"coverage"crown"retainer,"II)"par*al"coverage"crown"
retainer"includes"all"occlusal"surfaces,"III)"par*al"coverage"crown"retainer"includes"all"half"occlusal"surfaces"
of"molar,"IV)"Class"II"inlay"on"molar"and"box"inlay"on"the"premolar."V)"Inlay"box"for"both"abutments"saved"
with"par*al"coverage"crown"in"design"II""and"III.
approximately 6 degrees from the pulpal floor to
the occlusal surface with rounded internal line
angles. A finishing bur (HM 212L FG 016,
Meisinger, Germany) was used for smoothing all
preparation walls. Figure 3 shows the final
appearance of the five FPD designs.
II. Calculating Volume of Tooth Structure Loss
After the preparation had been complete, all
prepared teeth were dried with air pressure and
left on the laboratory bench for the next 24 hours
before weighing them. The volume loss of the
tooth structure with different designs was
calculated using Equation 1.
(1)
Where the V= volume of tooth structure loss,
W0= the weight of unprepared teeth, and W1= the
weight of the prepared teeth and D= density of
typodont tooth, which is made of poly methyl
methacrylate (PMMA) =1.2 g/cm3 (14).
The % Volume of the tooth structure loss in
the four conservative designs relative to the
volume of tooth structure lost with traditional
design was calculated using Equation 2.
%V loss = V1 / V0 x100 (2)
V1 is the volume of the tooth structure loss in
design II, III, IV or V whereas the V0 is the
volume of the tooth structure loss in the design I.
Data analysis
The statistical package Minitab 13 was used
for the statistical analysis of the results. Basic
statistics and One-way ANOVA with Tukey’s test
statistical analysis was used to measure the mean,
standard deviations (SD) and any other significant
differences between the volumes of the tooth
structure removed.
Results
For the lower first molar and lower first premolar
the volume of tooth structure loss (n=5) mean and
!12
Table"3:Volume"of"tooth"structure"loss"according"to"the"prepara*on"design
FPD"designs
Lower"first"molar Lower"first"premolar
Mean"volume"
removed"cm3 %"Volume"saved
Mean"volume"
removed"cm3 %"Volume"saved
Design"I 0.253"±"0.02""(A) 0.126"±"0.013"(A1)
Design"II 0.158"±"0.008"(B) 37% 0.071"±"0.007"(B1) 44%
Design"III 0.075"±"0.009"(C) 70% 0.070"±"0.009"(B1) 45%
Design"IV 0.048"±"0.005"(D) 80% 0.016±"0.002"(D1) 87%
Design"V 0.033"±"0.002"(D) 86% 0.017"±"0.006"(D1) 86%
Mean"with"different"lecers"are"significantly"different.

SD was shown in Table 3 for designs I, II, III, IV,
and V respectively. One-way ANOVA with
Tukey’s test statistical analysis of the results at
(p˂ 0.001), revealed that there was a highly
significant effect of the preparation design on the
volume loss of tooth structure respectively for
molar and premolar teeth.
The tooth structure saved with designs II, III,
IV and V were 37%, 70%, 80% and 86% for
lower first molar respectively. For lower first
premolar 44%, 45%, 87% and 86% for design II,
III, IV and V were saved compared with design I
as illustrated in Table 3 and Figure 4.
Volume tooth structure saved for both MO
inlay and box inlay in the molar design IV and V
was about twice that saved with partial coverage
crown in design II and little more compared with
design III . For lower first premolar with the box
inlay design IV and V was about twice that.
!
Discussion
Although preparation of one tooth is enough to
represent each design, five teeth were used for
each design to confirm the reproducibility. The
method used for calculating the relative tooth
structure loss for each design was remarkably
consistent as indicated by the low standard
deviation. Thus the use of only 5 specimens for
each group was adequate to prove statistically
significant differences. The teeth had been
weighed before preparation and after 24 hours in
dry fields. The amount of water absorbed by resin
materials after preparation with turbine/spray
application affect the weight measurement of
resin teeth (15). The measured weight was changed
to volume in cm3 using Equation 1. The choice of
the density of the resin was based on the
assumption that all resins have a very similar
density, being in the region of 1.2 g/cm3 (14).
Although the value used may not be strictly
correct it is unlikely to result in any significant
difference and will not affect the percentage
change in calculating volume loss. The typodont
teeth used in this study were selected to avoid
individual differences such as tooth morphology
and extension of the pulp.
The results of the present study suggest that
minimising the prepared surface area of the
abutment crown to receive all-ceramic resin
bonded FPD, offers a tremendous advantage over
conventional abutment crown preparations. In this
study three main FPD designs were applied,
which included a traditional all-ceramic FPD
abutments design, two innovative partial
coverage crowns retained FPD designs, with less
coverage area and a similar depth to the
traditional design depth, and two different designs
for inlay retained FPDs.
The results showed that the amount of tooth
structure loss was influenced significantly by the
preparation design. It should be pointed out that a
decrease in the prepared surface area increases the
volume percentage of tooth structure saved.
Design I showed highly significant tooth structure
loss compared with the other four more
conservative designs. The results also revealed a
significant difference between the conservative
designs themselves.
It was difficult to compare the results from
this study with those from other studies as there
are a limited number of papers in the literature
covering similar aspects. The methods used to
calculate the tooth structure removal for different
preparation designs also varied tremendously.
Edelhoff et al (2002) measured the loss of tooth
structure by weighing but the root was excluded
from the weight so it is difficult to compare his
!13
Figure"4:"Mean"volume,"±"SD"of"tooth"structure"loss"according"to"the"prepara*on"design,"teeth"n=5."Mean"
""""""""with"different"lecers"are"significantly"different"(ANOVA"one"way"with"Tukey’s"test,"p˂"0.001).

results with this study in terms of numbers.
However, in general, the conclusions were
consistent with this study. The Edelhoff et al study
showed that 39%, 27% and 5.5% tooth structure
were lost, versus 37%, 80% and 86% of the tooth
structure volume saved in this study, in partial
coverage crown, MO inlay inclusion transverse
ridge and proximal inlay box designs respectively
in both studies.
Location of the finishing line mesially for the
premolar and distally for the molar in designs II
and III made access for the preparation easier and
avoided disruption of the contact point with the
adjacent tooth. Losing this contact point would
have made it difficult to re-establish the original
position. Moving the finishing line location for
design II and III above the highest contour of
tooth structure bucally and lingually left more
enamel surface area compared with traditional
design and decreased the potential for irritation to
the gingival tissue. Retaining the preparation
within the enamel structure enhanced the bonding
action (13).
Conservative designs II and III provided
convenient access during preparation particularly
at the contact area. These results are in agreement
with the hypothesis that states that “the new
designs will significantly reduce invasiveness of
the FPDs abutment tooth preparations”. Although
the results of the minimal preparation design in
this study showed conservation in the volume of
tooth structure, what has not yet been considered
is whether or not the extension of the designs
provides a benign stress distribution. Further work
is needed to establish if the proposed designs
produce a sufficient benign stress distribution
under occlusal loading, to be clinically acceptable.
Conclusion
The amount of tooth structure sacrificed in the
proposed conservative FPD designs is
significantly less than that calculated for the
traditional design.
Acknowledgment
I would like to acknowledge with gratitude to the
staff of the Department of Academic Unit of
Restorative Dentistry of Sheffield clinical Dental
School.
References
1. Julien CK, Buschang HP, Throckmorton SG,
Dechow CP. Normal masticatory performsnce in
young adult and children. Archs Oral Biol.
1996;41:69-75.
2. Hattori Y, Satoh C, Kunieda T, Endoh R,
Hisamatsu H, Watanabe M. Bite forces and their
resultants during forceful intercuspal clenching in
h u m a n s . J o u r n a l o f B i o m e c h a n i c s .
2009;42:1533-8.
3. Lepley CR, Throckmorton GS, Ceen RF, Buschang
PH. Relative contributions of occlusion, maximum
bite force, and chewing cycle kinematics to
masticatory performance. American Journal of
Orthodontics & Dentofacial Orthopedics.
2011;139:606-13.
4. Edward AM. All-Ceramic Alternatives to
Conventional Metal-Ceramic Restorations.
Compendium. 1998;19( 3).
5. Pospiech P, Rammelsberg P, Unsold F. A new
design for all-ceramic resin-bonded fixed partial
dentures. Quintessence Int. 1996;37:753-8.
6. Rosenstiel SF, Land MF, Fujimoto J, Cockerill JJ.
Contemporary fixed prosthodontics: Mosby St.
Louis, MO; 2006.
7. Clausen JO, Abou Tara M, Kern M. Dynamic
fatigue and fracture resistance of non-retentive all-ceramic
full-coverage molar restorations.
Influence of ceramic material and preparation
design. Dent Mater. 2010;26:533-8.
8. Christensen GJ. Has tooth structure been
replaced. J Am Dent Assoc. 2002;133:103-5.
9. Edelhoff D, Dent DM, Sorensen JA. Tooth
structure removal Associated with various
preparation design for posterior teeth.
international journal of periodontics and
restorative dentistry. 2002;22:241-9.
10. Ramp MH, Mccracken MS, B.Mazer R. Tooth
structure loss apical to preparations for fixed
partial dentures when using self-limiting burs. 79.
1998:491-4.
11. Murphy F, McDonald A, Petrie A, Palmer G,
Setchell D. Coronal tooth structure in root-treated
teeth prepared for complete and partial coverage
restorations. Journal of Oral Rehabilitation.
2009;36:451-61.
12. Ivoclar V. IPS e.max all ceramic all you need
clinical guide/ glass ceramic preparation / IPS
e.max CAD /Scientific Documentation.10.
13. Shillingburg HT, Sather DA, Wilson EL, Cain JR,
Mitchell DL, Blanco LJ, et al. Fundamentals of
fixed prosthodontics Fourth edition ed. USA:
Quintessence Publishing Co.Inc; 2012.
14. Callister WD, Rethwisch DG. Materials science
and engineering: an introduction: Wiley New
York; 2007.
15. Edelhoff D, Sorensen JA. Tooth structure removal
associated with various preparation designs for
anterior teeth. J Prosthet Dent. 2002;87:503-9.
!14

Sulaimani Dent. J. 2014; 1:15-20 Rauf et al
Assessment*of*oral*hygiene*in*a*sample*of*orthodon/cally*
treated*pa/ents*using*different*bracket*materials*with*
different*mo/va/onal*techniques*in*Sulaimani*City
SDJ
Sulaimani*Dental*Journal
Aras M. Rauf, Tara A. Rashid, Ara O. Fatah, Fadil A. Kareem and Nyaz O. Mohammad*
Abstract
Background: Orthodontic treatment with fixed appliances alters the oral environment because oral cleaning becomes more
difficult with the presence of orthodontic appliance and its components. Numerous studies in the literature have evaluated the
oral hygiene motivational methods in orthodontic patients.
Objectives: To compare the effectiveness of three different motivational techniques for maintaining good oral hygiene during
the long term fixed orthodontic treatment.
Materials and methods: This comparative study was carried in Sulaimani city, on 60 patients with their age ranged from
12-18 years having fixed orthodontic appliances for a period of 18± 6 months were selected and divided randomly according
to motivational techniques into three study groups (A, B and C), each group was subsequently subdivided into 2 subgroups
according to the type of bracket material. The sample was subjected over a period of 6 months to different motivational
techniques during the orthodontic treatment. Oral health status was examined and recorded twice using simplified oral hygiene
index (OHI-S). The results were statistically analyzed with Statistical Product and Service Solutions software (SPSS, V16).
Results: After motivation and reinforcement, improvement of oral health was observed among the patients. Visual evidence
motivational technique (applied for group C) approved to be the most significant effective motivational technique (P≤ 0.001)
for patients undergoing orthodontic treatment regardless the type of the bracket material.
Conclusions: Orthodontists should concern about the motivation of the patients undergoing orthodontic treatment keeping
sustained oral hygiene throughout the treatment period. This study confirmed that visual evidence motivational technique is
the best educational and motivational technique for orthodontic patients that should be carried out before and throughout the
treatment.
Keywords: Oral health status, motivational technique, orthodontic treatment.
Received: October 2013, Accepted: January 2014
!
Introduction
Orthodontic treatment with fixed appliances alters
the oral environment, increases plaque amount, (1)
changes the composition of the flora (2) and
complicates cleaning for the patient (3) Gingivitis
and enamel decalcification (4,5) around fixed
appliances are frequent side effects when the
preventive programs have not been implemented.
The use of a fixed orthodontic appliance based on
brackets and archwires gives rise to retention
niches that pose an increased risk of caries (6,7,8).
Enamel demineralization around the brackets is
one adverse side effect that is of major clinical
relevance (9-12). Clinical studies have indicated
that orthodontic treatment may also be associated
with deterioration in periodontal health (13-15).
However, the majority of studies have concluded
that overall gingival alterations are transient with
no permanent damage to periodontal supporting
tissues (16-19).
One of the major and most common challenges in
prevention strategies within the field of oral
health is the control of plaque and, consequently,
the control of dental caries and gingival
inflammation (20-22). Mechanical methods such as
the use of toothbrush and dental floss, when
applied effectively, can promote proper plaque
control (23,24). Dental plaque should be monitored
before setting up the appliance and if patients are
motivated during the course of treatment, one can
prevent the gingival index from rising (25). It
seems to be that oral instructions alone, at the
orthodontist’s office, would not be sufficient when
a high level of oral hygiene is required during
orthodontic treatment. Other methods for patients’
motivation should be taken into consideration (26).
Mechanical methods of plaque removal require
time, motivation and manual skill (27). Up to our
knowledge, no previous studies investigated the
efficiency of various oral hygiene motivational
*Department*of**Pedodon/cs,*Orthodon/cs,*and*Preven/ve*Den/stry.*School*of*Den/stry/*University*of*Sulaimani.*
**Corresponding*author:*aras.rauf@univsul.net

techniques in our locality applied by the
orthodontists. The objective of this study was to
evaluate the efficacy of different motivational
techniques considering the type of bracket
material.
Methods
Ethical committee of the faculty of medical
sciences/ University of Sulaimani reviewed and
approved the protocol of the study; consent forms
of participation was signed by sixty orthodontic
patients (males and females) attending a private
orthodontic clinic who agreed to take part in the
study for a period of six months at least; inclusion
criteria were set as follows: A patient free from
systemic diseases and orthognathic surgery, no
previous orthodontic treatment with neither fixed
nor removable appliance and no extra-oral
orthodontic attachments. The patients were
divided randomly into 3 equal groups (A, B, and
C) according to the motivational technique to be
given. Each group was in turn subdivided into 2
equal subgroups according to the bracket material
(stainless steel and tooth-colored plastic brackets).
As a matter of standardization, all the patients
were trained on horizontal scrubbing technique of
tooth brushing and instructed to use oral-B
orthodontic brush with V-shaped bristles to
remove plaque from brackets and teeth. All the
patients were examined by a trained orthodontist
and oral hygiene status was evaluated twice,
before and after the motivational course. In
addition to the information regarding the oral
healthcare practice and behavior; oral health
status was examined using simplified oral hygiene
index (OHI-S) which was modified by Greene
(1967) that is adopted by the world health
organization (WHO) for such epidemiological
studies (28). Each group was subjected to a
different motivational technique as follows:
Group A: Classical motivational technique:
Patients were motivated through conventional
plaque control measures which means the plaque
disclosed with 2% mercurochrome. The
composition of plaque, its effects on oral health,
and the importance of its removal were stressed,
and a horizontal scrubbing technique of brushing
was demonstrated to the patients.
Group B: chair-side motivational technique: In
this method an indicator dye, Bromocresol green,
was demonstrated to change color from green to
yellow on addition of a drop of 0.1NHCl acid in
the depression of a color plate. This step was
carried out to show the patient that the change in
color of the dye is due to a drop in pH because of
the addition of acid. A pooled plaque sample from
the patient was then put into another depression of
the color plate containing 1 drop of indicator dye
which did not show any evident color change.
This was followed by 10% glucose rinse for
1 minute by the individual. After 8–10 minutes,
pooled plaque was taken from the patient's mouth
and put into another depression of the color plate.
A drop of bromocresol green dye was added to the
collected plaque. On addition of the dye, a color
change occurred from green to yellow, and the pH
dropped after a glucose rinse, depicting the acidic
nature of dental plaque. In order to motivate the
patients to regularly remove dental plaque, the
effect of sweet foods on the production of weak
acids in dental plaque by microorganisms was
described to the patients. These weak acids
initiate demineralization of enamel leading to
cavity formation and other by-products of dental
plaque bacteria that irritate gingival tissue to
produce gingivitis. In addition, as in group A,
conventional plaque control measures were also
demonstrated to the patients.
Group C: visual evidence motivational
technique. For this group of the patients, a
!16
Table*1.*Characteris/cs*of*the*study*sample
Descrip(ve*sta(s(cs
Variables No. Total
Number*of*pa/ents males 30
60
females 30
Bracket*type metal 36
60
plas/c 24
Frequency*of*tooth*brushing Once*a*day 38*****63.3%
Twice*a*day 18*****30% 60
No*regular*brushing 4*****6.7%
Reason*behind*treatment cosme/c 51****85%
60
func/onal 9*****15%

prerecorded video of the plaque bacteria was
shown to the patients. This was followed by
plaque disclosure with 2% mercurochrome and
demonstration of a horizontal scrubbing method
of brushing as done in the former groups.
Clinical examination
Each patient was seated on a dental chair in an
upright position under light illumination with the
head tilted slightly backward and supported
against the headrest of the dental chair in such a
manner that the mandibular plane be parallel to
the floor while the patient opens his/her mouth.
Clinical examination started first from upper left
posterior side, forward to the upper right side,
down to the lower right side then passing through
the lower anterior region to the lower left side.
The preselected tooth surfaces were examined for
the presence and extension of debris and/or
calculus for scoring, by moving the WHO probe
across the surfaces and gingival margins,
reflecting the cheeks and lips with a disposable
mirror. All the scores were recorded in a specially
designed case-sheet for this purpose. The data
were analyzed with SPSS (V.16) software to
declare the results and to test the hypothesis with
the degree of confidence set for less than 0.05.
!
Results
The initial descriptive statistics showed that
63.3% of the sample (13 males & 25 females) was
brushing their teeth once a day, 30% of them (7
males & 11 females) twice a day, while the other
6.7% (2 males & 2 females) were declared to have
no regular tooth brushing routine. The majority of
the patients (85%) reported that the reason behind
the orthodontic therapy is cosmetics, and the rest
(15%) were suffering from functional and esthetic
problems as shown in table 1. At the beginning of
the study, the oral hygiene of the patients was
noticeably deteriorated table 2. The result of
paired t-test showed that there was a highly
significant difference in the oral health status
between pre and post-motivational action with the
p value presented to be less than 0.001 table 3.
Data analysis for independent factors (gender,
type of the bracket and age of the patient)
clarified that the only factor that significantly
correlated with improvement of oral health and
lowered the oral hygiene simplified index after
implementation of the educational program is the
type of motivational technique tables 4 and 5.
!
Discussion
In fixed orthodontic treatment, plaque retention
surfaces are increased and, as a result, most
patients are confronted with hygiene difficulties,
which eventually cause elevated plaque indices
(29). Frequent patient visits for orthodontic
maintenance are opportunities for the dentist to
teach techniques that promote oral hygiene, and to
reinforce instructions that encourage healthy
habits (30). In order to promote and maintain
satisfactory oral health, orthodontic patients
should undergo a stringent program of oral
hygiene and dental plaque control before and
during orthodontic treatment (31,32). Feliu (30)
demonstrated that patients undergoing orthodontic
treatment may have lower levels of plaque and
gingival inflammation than patients who are not
under orthodontic treatment provided that they
first attend an educational preventive program.
Silva et al (33) showed that one group of
orthodontic patients who received oral hygiene
instructions only on the first day of treatment did
not change their habits while the other group, who
was given instructions every fortnight throughout
the period with hygiene classes and motivation
!17
Table*2.**Descrip/ve*analysis*of*pre*and*post*mo/va/on*OHIS
OHI7S No. Minimum*Value Maximum*value Mean*value SD
Premo/va/on*index 60 1.3 4.1 2.881 0.69
Postmo/va/on*index 60 0.09 3.8 1.495 0.975
Table*3.*Paired*mean*differences*between*pre*and*post*mo/va/on*OHIS
OHI7S Paired*Differences
T df p7*value
Mean SD SE
Preindex*–*
postindex 1.386 0.9802 0.1265 10.951 59 0

and were monitored with a plaque control chart,
achieved a better oral hygiene index. The current
health paradigm requires that patients be regarded
as one single whole. Health promotion and
disease prevention should be part of the
philosophy adopted by orthodontists in caring for
their patients. Furthermore, professionals should
provide guidance and motivation to their patients
regarding oral health care before and during
orthodontic treatment (34).
Methods of educating orthodontic patients are
generally classified as verbal, (35-37) written, (38) or
visual based (videotapes) (39). In this study, all
patients received oral hygiene education before
treatment and the information were reinforced
throughout the period of the study. As expected,
the three types of the educational methods applied
in this study had impact on improving oral health
of the participating patients; however, group C
with visual evidence education seen to be the
most effective approach for lowering the Oral
hygiene index; the reason behind this difference
might be contributed to the fact that, using more
than one educational aid to provide instruction
and reinforcement leads to retention and retrieval
of the information. Boyd (37) evaluated the
effectiveness of the self-monitoring plaque
control. Huber (40) investigated the efficiency of
repeated professional prophylaxis together with
reinforced oral hygiene instruction on a monthly
basis and found that the monthly professional
prophylaxis had a significant effect in reducing
the gingival enlargement routinely associated with
fixed orthodontic appliances. Yeung (41) conducted
an oral hygiene program consisting of four
weekly sessions of oral health education and
instruction of plaque control techniques. McGlynn
(38) studied the effectiveness of an oral hygiene
booklet and repeated lectures with professional
prophylaxis. No significant differences between
the booklet and lecture groups were found. On the
other hand, Lees et al (30) found no significant
differences between the written, verbal, and
videotape instruction methods.
!
Conclusion
This study confirmed that visual evidence
motivational technique is the best educational and
motivational technique for orthodontic patients
that should be carried out before and throughout
the treatment. We hypothesize that solely verbal
recommendations are not enough to achieve
optimum plaque removal, and that the
ameliorations of the patients' inaccurate oral
hygiene efforts by the specialists at the same
session are essential.
!!
!18
Table*4.*Prepost*index*correla/on*regarding*gender,*age,*bracket*type,*and*mo/va/onal*technique.
Pre7index gender age Bracket*type
Mo(va(onal*
technique
Postindex
Pearson*Correla/on 0.3 0.024 0.089 0.0799 0.7705
Sig.*(2tailed) 0.006 0.85 0.496 0.5437 0
N 60 60 60 60 60
Table*4.*Mul/ple*regression*analysis*of*the*post*OHIS*as*a*dependent*variable*and*several*covariants.
Unstandardized*Coefficients
Standardized*
Coefficients
t Sig.
B Std.*Error Beta
Gender 0.0989 0.165 0.05087 0.5988 0.551
Age 0.0276 0.047 0.0497 0.5851 0.56
Brackettype 0.1504 0.163 0.07775 0.9176 0.362
Mo/va/on 0.9127 0.1005 0.77033 9.0772 0

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!20

Sulaimani Dent. J. 2014; 1:21-28 Abdul-Rahman
Evalua2on(of(microleakage(in(the(gingival(margin(of(class(II(
resin(composite(restora2on(when(using(three(placement(
techniques((An(in(vitro(study)
Miwan S. Abdul-Rahman*
SDJ
Sulaimani(Dental(Journal
Abstract
Objective: To evaluate and compare the effect of bulk and layering composite filling techniques on the gingival
microleakage in class II cavity.
Materials and methods: Standardized 60 class II cavities were prepared in the proximal surfaces of thirty extracted non
caries permanent molars and randomly were divided into two main groups A and B each composed of 30 cavities, for
group (A) the gingival floor on mesial side was prepared one mm above the CEJ and for group (B) one mm below the CEJ,
then each main group was subdivided into three subgroups (n=10 cavities) according to the composite placement
technique: 1) bulk, 2) horizontal, 3) oblique. The specimens were immersed in a solution of 2% methylene blue dye for 24
hours. The microleakage scores (0 to 3) were obtained from the cervical surface and the cervical microleakage was
analyzed with a stereomicroscope.
Results: The gingival dye penetration increased when the gingival floor was below the CEJ. The microleakage is increased
with bulk followed by horizontal and oblique.
Conclusion: This study predicts that the oblique layering composite filling technique of class II is betters then the other
techniques when the gingival floor is above and below the CEJ.
Keywords: Gingival dye microleakage, Nano-hybrid resin based composite, bulk placement techniques, incremental
placement techniques.
Received: September 2013, Accepted: February 2014
!
Introduction
Posterior composite restorations have been shown
to produce higher failure rates due to secondary
caries, which can be directly linked to marginal
integrity (1,2). This is the result of composite resin
polymerization shrinkage, which may be
responsible for the formation of a gap between
composite resin and the cavity walls, and it may
be filled with oral fluids and bacteria (3). Other
adverse consequences of polymerization
shrinkage stresses include coronal deformation
resulting in postoperative sensitivity, propagation
of existing enamel microcracks, and micro cracks
of composite resin due to cohesive failure (4).
Several efforts have been made to decrease these
polymerization shrinkage stresses and were
directed toward improving composite resin
formulation, curing methods and restorative
placement techniques (5). Although the mechanical
properties and abrasion resistance of resin-based
composites have improved considerably over the
years, the placement technique of posterior resin-based
restoration remains very technique sensitive
and regarded as a major factor of influence for
clinical performance of class II composite resins
fillings (6,7).
Different composite placement techniques
have been recommended (bulk technique and
layering technique). Using bulk technique,a high
internal stresses may be generated in the material
and loss of marginal integrity can occur (7).
Layering or incremental techniques, in contrast to
bulk packing methods, have decreased marginal
gaps (8). Furthermore, layering techniques has
been advocated for use in large composite
restorations to decrease the overall contraction by
reducing the bulk of material cured at one time (9).
Layering composite filling techniques also
reportedly enhances complete polymerization by
reducing the required depth of cure and enhance
esthetic results from the multi-layering of color
and also improve marginal seal (10).These
techniques include the horizontal (Gingivo-occlusal
layering), the wedge-shaped oblique
layering, the successive cusp buildup technique,
the split-increment horizontal placement
technique, vertical (facio-lingual layering) and
centripetal placement (5,11).
In this study we investigated the influence of
horizontal and oblique techniques on gingival
microleakage in class II composite filling
compared with bulk technique. The horizontal
*Assistant(Lecturer,(Conserva2ve(Den2stry,(School(of(den2stry,(Faculty(of(Medical(Sciences,(University(of(Sulaimani/(Iraq.(
(ECmail:(meewan77@yahoo.com

layering technique is the traditional way to fill
the cavity, the thickness of each increment of
resin composite is not more than 2 mm. Each
increment shall be fully polymerized before the
next one is inserted into the cavity (12), while in
oblique layering technique; wedge-shaped
composite increments are placed and polymerized
only from the occlusal surface (13).
Materials and methods
Thirty extracted non caries human permanent
molars were selected; the teeth were scaled to
remove any calculus and polished with pumice to
remove plaque and debris.Then all the selected
teeth were kept in distilled water at 4°C for 24 h.
Two sound extracted molars were embedded in
dental stone to the level of 3 mm below the
cementoenamel junction (CEJ) and the test
specimen was embedded between these two teeth
(Fig. 1.a). Sixty Class II MO/DO cavity
preparations were made on each side of the teeth
using a straight fissured diamond bur (No.010) in
a high-speed handpiece and copious amounts of
water. The teeth were divided into two main
groups as shown in (Fig.2): (Group A), (n=30
cavities); the gingival floor on mesial side was
prepared one mm above the CEJ; and (Group B),
(n=60cavities); the gingival floor on distal side
was prepared one mm below the CEJ. No bevels
were placed at any of the cavosurface margins.
All the cavities were etched then a light-curing,
single-component bonding agent for
enamel and dentin was applied (Tetric N-Bond,
Ivoclar, Vivadent) (Fig. 1. d) and cured for 40
seconds as per manufacturer's instructions. After
the preparations were completed, each main group
was subdivided into three subgroups (n=10
Figure(2.(The(division(of(the(study(groups.
cavities) as shown in (Fig. 2), then a tofflemire
universal matrix retainer is positioned from the
buccal surface of the test molar (Fig. 1-b). The
tofflemire band was contoured and firmly wedged
to closely adapt the matrix to the gingival margin
of the preparation and to achieve a degree of tooth
separation in order to compensate the matrix
width. Then the teeth in all groups were restored
with a Nano-hybrid resin based composite (Tetric
N-Ceram, Ivoclar, Vivadent). The manufacturer
instruction was followed; the light curing was
done using Cool Blue TM LED (Milestone
Scientific, Livingston, NJ, USA) with a light
intensity of (400 mW/cm 2). The composite
restorations were placed in each group according
to the techniques shown in (Fig.3).
After removal of the metal band, all the
specimens were stored in distilled water at 37°C
for 24 hours; the restored teeth were subjected to
artificial aging by thermocycling. All the
specimens were immersed alternatively in water
baths at 5 °C and 55 °C for 1500 cycles with a
dwell time 30 seconds and a transfer time of 15
seconds. In order to prevent dye penetration into
N22
(a)$ (b)$
(c)$ (d)$
Figure( 1.( (a)( shows( the( embedding( test( specimen( between( two( molars( in( dental( stone,( (b)(
illustrates(the(acid(itching(procedure,((c)(displays(the(bonding(procedure,( ((d)(shows(the(tooth(at(
the(end(of(the(filling(procedure.

N23
Group(1.(Bulk(placement(technique(((((((((((((((((((Group(2.Horizontal(layering(technique(((((((((((((Group(3.Oblique(layering((technique
Figure(3.(Placement(techniques(of(the(composite(resin(according(to(the(groups.
Figure(4.(The(two(halves(of(the(sample(aVer(being(sec2oned(mesioCdistally(through(the(center.
Figure(5.(The(point(selected(to(scores(of(the(dye(penetra2on,(when(the(gingival(floor(is(
above(and(below(the(CEJ.
((((((((((((((((((((((((((Group(A3((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((Group(B1(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((Group(B2(
Figure6.(Samples(of(the(specimens,(the(red(arrow(shows(the(gingival(dye(pentra2on;(
( ( ( ( ( ((Groups;(A3((score(0),B1((score(3)(and(B2((score(2)

Figure(7.(The(gingival(microleakage(scores(above((A)(and(below((B)(CEJ(of(the(groups
Figure( 8.( Mean( of( the( gingival( microleakage( scores( above( (A)( and( below( (B)( CEJ( of( the( three( placement(
N24
technique(groups
Table(1.(The(gingival(microleakage(scores(above((A)(and((B)(The(CEJ(of(all(the(groups
Groups
SCORES
0 1 2 3
Above(CEJ A1((bulk) 4 6 0 0
A2((horizontal) 6 4 0 0
A3((oblique) 8 2 0 0
Below(CEJ B1(bulk) 0 7 2 1
B2(horizontal)( 4 5 1 0
B3((oblique)( 5 5 0 0

Table(2.(Mean(and(standard(devia2on(values(of(the(gingival(microleakage(Scores(above((A)(and((B)(the(CEJ(of(all(
the(groups((N10)
Groups Mean St.4deviaEon Variance
Group(A((Above(CEJ) A1 0.6 ±(0.516 0.267
the dentinal tubules and lateral canals, the apices
were sealed with sticky wax then the teeth surface
were isolated with two layers of nail varnish
except for one mm around the restoration, The
specimens were immersed in a solution of 2%
methylene blue dye for 24 hours at 37°C. The
sticky wax was removed following the dye
exposure. Then after the nail varnish was
removed, the specimens were sectioned through
the center of the restoration mesio-distally with
diamond disk (Fig.4). The cervical microleakage
wa s a n a l y z e d a n d r e c o r d e d wi t h a
stereomicroscope at 10X magnification for the
degree for dye penetration along the cervical
walls as shows in (Fig.5) using the following
score;
0= no dye penetration, 1= dye penetration
extending into 1/2 of the cervical wall, 2= dye
penetration into more than 1/2 or a complete
extension of the cervical wall, 3= dye penetration
into cervical and along the axial walls. The data
N25
A2 0.4 ±(0.516 0.267
A3 0.2 ±(0.422 0.178
Group(B((Below(CEJ) B1 1.4 ±(0.699 0.489
B2 0.7 ±(0.675 0.456
B3 0.5 ±(0.527 0.278
Table(3.(student(tCtest(to(compare(the(gingival(microleakage(between(the(three(placement(technique
Groups Mean4
differences
Paired4differences 95%4confidence4interval4
of4the4difference Std.4 St.4Error4
df Sig.
deviaEon
mean tGtest
upper lower
Group(A(
(Above(CEJ)
A1CA2 0.2 0.516 0.163 0.866 0.685 0.285 18 0.398(NS
A1CA3 0.4 0.516 0.163 1.897 0.843 0.043 18 0.074(NS
A2CA3 0.2 0.516 0.163 0.949 0.643 0.243 18 0.355(NS
Group(B(
(Below(CEJ)
B1CB2 0.7 0.699 0.221 2.278 1.346 0.054 18 0.035(S
B1CB3 0.9 0.699 0.221 3.25 1.482 0.318 18 0.004(HS
B2CB4 0.2 0.675 0.213 0.739 0.769 0.369 18 0.470(NS
Table(4.(student(tCtest(to(compare(the(gingival(microleakage(above((A)(and(Below((B)(CEJ(between(the(
placement(technique(groups
Groups
Mean4
differences
Paired4differences
95%4confidence4interval4
of4the4difference df Sig.
Std.4
deviaEon
St.4Error4
mean
tGtest
upper lower
A1CB1 0.8 0.516 0.163 2.91 0.223 1.377 18 0.009(HS
A2C(B2 0.3 0.516 0.163 1.116 0.265 0.865 18 0.27((NS
A3C(B3 0.3 0.422 0.133 1.406 0.148 0.748 18 0.177(NS

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