Illica crest bone graft Ectodermal DysplasiaProsthodontic Management of Ectodermal Dysplasia with Iliac bone graft and endosseous implants : A case report
Dr Neeraj Nagpal , Dr K L Gupta, Dr Ruchi Nagpal, Dr Dhruv Sharma
ABSTRACT : Ectodermal dysplasia is a rare congenital disease that affects several ectodermal structures . Persons suffering from ectodermal dysplasia may have various manifestations of the disease that differ in severity and may or may not involve teeth, skin, nails , seat and sebaceous glands. The most common form of ectodermal dysplasia syndrome is hypohidrotic ectodermal dysplasia and is usually inherited as an X- linked recessive trait .Female carriers have a variable degree of clinical manifestations . This case report discusses prosthodontic management of an 18 year old female suffering from ectodermal dysplasia . Clinical management consisted of iliac crest autogenous bone graft to augment premaxilla . Later 2 endosseous implants placed in premaxilla and 2 endosseous implants placed in parasymphysis region of the mandible. After Osseointegration of the implants a four unit fixed partial denture placed in maxilla and an implant supported over denture fabricated for mandibular arch. Keywords : Ectodermal dysplasia , Christ Siemens syndrome ,Hypohidrosis , Hypotrichosis , Hypodontia . Introduction : Ectodermal dysplasia is a hereditary disorder manifested as dysplasia of tissues of ectodermal origin primarily nail, teeth skin and occasionally dysplasia of mesoderm derived tissues . As defined by Freire – Maia the nosologic group of Ectodermal dysplasia is any syndrome that exhibits at least 2 of the features ,that is ,abnormal hair (trichodysplasia ) , abnormal dentition , abnormal nails (onchodysplasia ) and abnormal or missing seat glands (dyshidrosis ) . More than 150 different variants of Ectodermal dysplasia have been described . Hidrotic and hypohidrotic are the 2 forms of Ectodermal dysplasia . In both types teeth and hair are similarly affected , but manifestations in nails and s eat glands and the hereditary pattern tend to differ  . The X- linked hypohidrotic form or Christ Siemens syndrome is characterized by clinical triad of hypohidrosis , hypotrichosis and hypodontia . Hidrotic form is inherited as an autosomal dominant trait and affects teeth , hair , and nails but usually spares the s eat glands .Prosthodontic rehabilitation is of paramount importance in patients suffering from Ectodermal dysplasia for functional , physiologic and psychologic reasons . Case Report : An 18 year old female named Reena reported with multiple missing teeth since birth. Her parents reported in difficulty in getting her married due to poor look resulting from several congenitally missing teeth. After clinical and radiographic examination the case diagnosed as Anhidrotic Ectodermal Dysplasia . Family history of Ectodermal dysplasia as negative . The young lady as moderately built with hypotrichosis , scarce eyebrows and scarce eyelashes , dry anhidrotic skin , depressed nasal bridge , thin lips ,dark pigmented skin around periorbital area and nose , facial height as reduced ( fig . 1 ) She reported absence of eat and that her lips and tongue remain dry in all climates . There was no relevant effect on the nails . Intraoral examination revealed presence of partially erupted four teeth in the region of 13, 16, 23 and 26 ( fig 2, 3 ). The edentulous ridge as atrophic with decreased height . the palate as shallow , oral mucosa as normal and dry due to less saliva , the tongue as relatively large . OPG X ray depicted poorly developed premaxilla and completely edentulous mandible .( fig 4 ) Surgical and Prosthodontic Management Initially the impacted canine in the mandibular arch as surgically removed ( seen in the OPG fig 1 ). The ridge augumentation of the premaxilla was done with the help of an autogenious bone graft taken from the patients iliac crest( fig 2 ). Hence, the residual alveolar ridge made suitable for the implant placement .Three implants were placed in the mandibular arch in C,B and D positions , followed by the fabrication of an implant supported mandibular overdenture .
In the maxillary arch ridge the ridge augumentation was done with the help of a iliac crest graft Henceforth , a tooth supported fixed prosthesis i.r.t 24,25,26 as fabricated . Followed by the placement of 2 implants in the premaxillary segment .After three months of osseointegration , a four unit implant supported fixed prosthesis replacing 11 ,12 ,21 and 22 as fabricated .
An iliac crest bone graft as harvested ( fig 3 ) and stabilized to augment the premaxilla ( fig 5 ) .The iliac crest is preferentially selected because it is an autogenous cancellous bone graft and is easily harvested and has predictable acceptance and biointegration . After 2 months of bone augmentation 2 endosseous implants were placed in the augmented premaxilla( fig 6 ). Osseointegration of the implants as allowed for four months , followed by fabrication of four unit fixed partial denture prosthesis in 11, 12, 21and 22 regions. Impression as made using elastomeric impression material by putty ash technique .Abutment analogues and implant analogues were placed in the impression . The impression as poured in die stone by split cast technique. Later three endosseous double stage implants were placed in the mandibular arch ( fig 7 ). After four months of Osseointegration , the implants were uncovered , the abutments ere attached and a customized impression as made , after border molding , in rubber base impression material. The mandibular arch rehabilitated with implant supported overdenture ( fig 8 ) due to economical constraints and ease of rehabilitation .The denture as fabricated from heat cured P.M.M.A. (Trevalon powder and liquid , Dentsply ) .The intaglio surface of the denture as relieved and the female housings of the implant attached using autopolymerising acrylic resin P.M.M.A. (Dentsply ) There as marked improvement in speech and the facial esthetics . Discussion The treatment for a patient of Ectodermal dysplasia varies and generally depends on the persons age , dental agenesis , degree of malformation of teeth , the growth and development of the stomatognathic system of the patient and patient’s motivation . According to Nowak  treating the ectodermal dysplasia patient requires the clinician to be knowledgeable in growth and development , behavioral management , techniques in fabrication of prosthesis , the ability to motivate the patient in the use of the prosthesis and the long term follow -up for the modification and/ or replacement of the prosthesis . Prosthodontic treatment for ectodermal dysplasia includes removable partial denture or complete denture , overdenture and implants .These approaches may be used either individually or in combination to provide optimal results . Early prosthodontic treatment is generally recommended from the age of 5 years . This early restoration of facial appearance is essential for normal psychological development .  . Rapid growth in early life dictates the use of removable partial or complete dentures for these patients. When full growth is reached, treatment planning may include dental implants to retain, support, and stabilize prostheses. Osseointegrated implants offer an alternative that will provide major improvement in the long-term prognosis for oral rehabilitation. In treatment planning for implant dentistry in these patients, extra care must be taken to determine whether adequate bone level to receive the implants is present and whether there is adequate vertical dimension of bone to support the implants. Diminished bone volume may limit the success of implants, especially in the maxilla . The problems associated with complete denture placement in an ectodermal dysplasia case are mainly associated with periodic adjustment due to growth changes and difficulties in achieving good retention and stability  .Difficulties in achieving adequate resistance to lateral and anteroposterior displacement of the denture in hypohidrotic ectodermal dysplasia patient are due to dryness of oral mucosa and underdevelopment of maxillary tuberosities and alveolar ridges . If few teeth are present in the mouth, overdentures are the most desirable treatment options [1,3].Overdentures help in preservation of the alveolar bone . Due to decreased number of abutments conventional fixed prosthodontic treatment needs to be altered . Dental implants may be placed in specific areas of the alveolar ridge to gain support for the FPD . For adult patients with ectodermal dysplasia , dental implants are the treatment of choice because growth has stabilized and implants may be used to support , retain and stabilize the prosthesis . In this case of an 21 year old female and the premaxilla being poorly developed . Hence, an iliac crest autogenous bone graft used to augment the premaxilla followed by placement of 2 endosseous implants . The implants were later rehabilitated with a four unit porcelain fused to metal fixed partial denture . The treatment not only improved the patient- s functional and esthetic status (fig 7 ) but also improved the psychological wellbeing and the social life. Conclusion The study discusses the management of a young lady with Anhidrotic Ectodermal Dysplasia having multiple missing teeth and atrophic partially edentulous maxilla and edentulous mandibular ridge . A prosthodontic rehabilitation consisted of bone augmentation of premaxilla with iliac crest autogenous bone graft . Subsequently , 2 endosseous implants were placed to support a four unit fixed partial denture . An implant supported overdenture fabricated for completely edentulous mandibular arch . Hence , physical , physiological and psychological status of the patient as optimally restored . References 1.Pigno MA , Blackman RB ,Cronin RJ ,Cavazos E (1996 ) Prosthodontic management of ectodermal dysplasia :a review of literature . J Prosthet Dent 2.Pinheiro M ,Freire-Maia N (1994 ) Ectodermal dysplasias : a clinical classification and a casual review . Am J Med Genet 53 : 153- 162 3.Bonilla ED , Guerra L , Luna O (1997 ) Overdenture prosthesis for oral rehabilitation of hypohidrotic ectodermal dysplasia : a case report . Quintessence Int 28 (10): 657-661 Tarjan I , Gabrir K , Rozsa N (2005 ) Early prosthetic treatment of patient with ectodermal dysplasia : a clinical report J Prosthetic Dent 93 : 419-424 REFRENCES
1.Hickey A, Vergo JR TJ: Prosthetic treatments for patients with ectodermal dysplasia. J Prosthet Dent 2001;86:364- 368. 2.Guckes AD, Scurria MS, King TS, et al: Prospective clinical trial of dental implants in persons with ectodermal dysplasia. J Prosthet Dent 2002;88:21-25. 3.Dhanrajani PJ, Jiffry AO: Management of ectodermal dysplasia: a literature review. Dent Update 1998;25:73-75 4.NaBadalung DP: Prosthodontic rehabilitation of an anhidrotic ectodermal dysplasia patient: a clinical report. J Prosthet Dent 1999;81:499-502 5.Pigno MA, Blackman RB, Cronin RJ, et al: Prosthodontic management of ectodermal dysplasia: a review of the literature. J Prosthet Dent 1996;76:541-545 6.Blattner RJ: Hereditary ectodermal dysplasia. J Pediatr 1968;73:444-447 7.Davarpanah M, Moon JW, Yang LR, et al: Dental implants in the oral rehabilitation of a teenager with hypohidrotic ectodermal dysplasia: report of a case. Int J Oral Maxillofac Implants 1997;12:252-258 8.Bolender CL, Law DB, Austin LB: Prosthodontic treatment of ectodermal dysplasia. A case report. J Prosthet Dent 1964;14:317-325 9.Snawder KD: Considerations in dental treatment of children with ectodermal dysplasia. J Am Dent Assoc 1976;93:1177-1179 10.Guckes AD, Brahim JS, McCarthy GR, et al: Using endosseous implants for patients with ectodermal dysplasia. J Am Dent Assoc 1991;122:59-62 4. Sha RM (1990 ) Prosthetic management of hypohidrotic ectodermal dysplasia with anadontia : case report . Aust Dent J 35 : 113-166
If you don’t know what you should do, dealing with anger and its results is likely to be a losing endeavor. Because they don’t know how to handle stress, many people lash out with fits of rage and anger. Just about everybody, except young children perhaps, easily recognize that they are having a issue with anger that is not under control. Although there are a lot of anger management activities around they are just uneducated regarding these activities and techniques.
When living everyday with angry feelings, there are a lot of anger management activities people use and get involved in. To help, exercise is one activity that is urged. Exercise has been tested to have an uplifting effect on human moods. Exercise also helps you get rid of negative feelings. Good anger management activity could be as simple yet profound as taking a walk or jog. Working out with weights or playing a favorite sport. These all work well as anger management activities. Going hiking or spending a few hours out in nature will also help you to clear your head and release tension. An outdoor anger management activity creates a helpful environment.
Anger management activities like a support group; retreat or camp helps people to deal with their anger. One good thing about participating in anger management activities is you would be able to see firsthand that your situation is not unique. You will see that it is shared by a lot of other people. Sharing with people in with the same situations is one of the keys to anger management for many. Sharing with others has the reputation of providing angry people with help as they listen to success stories. In anger management activities like these, people are dealing efficiently with their anger issues through various group sessions, activities, and one on one consultation.
Anger management activities should be used with children who have anger problems. Children are not going to respond properly to group sessions and will eventually become bored with one on one meetings. Having activities that are fun to a child is a better alternative because children enjoy fun and games. Doing anger management activities that are beneficial and enjoyable is so much more effective than having children sit with anger management counselors. Interactive games and other activities like coloring pages, worksheets, and individual games are more accepted by children than trips to the psychiatrist. When it involves children, it is important to understand and approach the problem skilfully. Being overbearing is not going to go over good with children. When considering anger management activities for kids, remember that an interesting approach is important because after all they are only children.
When considering anger management activities, you should choose activities that are enjoyable and helpful to you. The reason is because if you do not like the program you will not keep working at it. Your key focus should be on finding effective activities that you like.
As for you though, if you want to be expressing your anger properly in less than 48 hours, go to http://www.the-anger-management-store.com, I have free videos there that tell you more about it.
To ensure the real-time monitoring of your network and manage vast quantities of system events, you need to seek the help of network management software. This software is used effectively by small to medium companies and even by some large companies to monitor and support the entire LAN infrastructure. It successfully monitors wireless routers, switchers, firewalls, servers, printers, and even non-standard devices. This software ensures smooth functioning of the computers in your office.
The technical issues in network management will be solve, principally if business uses numerous number of computers, because the software functions in a high precision and high paced performance level. The management network software will manage technical difficulty on security in relation to internet and other web-based applications. Every businessman should get this software if they are serious with urbanization of their network management.
Mostly service oriented corporations would want to keep their clients , therefore they want to attain their legal and agreement obligations proficiently. If you are a businessman responding to the wishes of your clients, it is logical to keep your services to meet their standards and prevent them from transferring to another service company. With the aid of a reliable network management, you will be able to respond to the standards of your business to retain your business’ trustworthy reputation. It will be more useful to load your business with good software to determine internet traffic blocks and guarantee precise connectivity. This will help in the transmission of information issues for your clients. In the utilization of a network management, software is required to provide the entire company’s requirements. So ,before you procure a service, make sure to elaborate the things that should be done to the partner producer or supplier so they can handle all the processes accordingly.
The functions of standard network management software are not confined to network monitoring alone. This type of software also:
Ensures network security and proper management of information systems. It’s crucial to periodically monitor security events and conduct a systematic analysis of your system’s security logs. You should remember that security threats are not always from an outside source. Very often, they occur internally and where it is not possible for a firewall to operate.
Assures legal and compliance obligations to protect your company from audit suits and contractual disputes. It provides the necessary tools to go further back in time to follow audit trails. This is important to protect your company from the impending doom of a lawsuit.
Contains a state of the art web interface, so you can have a unified view into the many hundreds of nodes and interfaces in your office network. Regularly monitored features include the size of bandwidth used, errors, discards, and the quality of service.
The best about network management is its feature to record or analysis on any hardware crash and alerts the network manager of a potential risks. Before a more serious damage occurs, a prompt will tell the staff that there is danger on the following areas. Expect the management software to present a system status and or relevant information to the network administrator your firm. If anything happens, event logs can be useful for future orientation.
A capable IT management must determine the potential technical risk. The main function of the network management is to perform network monitoring, troubleshooting technical problems in an open network, accurate scheduling of business necessary applications, and managing help desk tickets at maximum time feasible.
Application monitoring and availability are very important to retain your clients, which is done by constantly checking on the behavior and performance factor of applications. IT management also calls for tools that reduce operational cost and improve the performance factor of the company by systematically integrating and simplifying their network. If you’re looking for a network management software solution for your business, there are a number of companies online providing efficient management software to fit your budget.
Does it ever seem like you need more than 24 hours in your day? Is your work life and home life clashing together? The problem is not that we need more time but that we need to learn to use time more wisely. The best way to get started organizing your life and ridding yourself of the insanity is to read these efficient effective time management techniques.
The Basics of Time Management
To start taking control of your life you must first know what you need to get done. So every morning make a list of things that need to get done that day, or for a better nights sleep make a list the night before. This way you don’t have to keep thinking and remembering to remember all these things through out the night.
After you accomplish your goal mark it off on your schedule of tasks. It gives you a peace of mind and the encouragement to continue on with your day.
* It is advisable to review your list at the beginning of the day so that you can arrange your schedule in the most efficient manner possible. You should also avoid making your list too tight that there is no room for making adjustments. There will always be unforeseen events and you should take these into consideration.
* If you have an appointment be sure to make a call to them and see if the appointment is still on. You don’t want to waste time going all the way over there and find out that it’s been canceled. You could have use that time to get other things done.
Learn to Say No
All too often, people find themselves in over their head in projects and other commitments simply because they don’t have the heart to say no to a client or a friend in need. However, if you stretch yourself too thin, you will no longer be able to perform to the best of your abilities and this will compromise the quality of your results.
Before accepting any project or making any commitment, you first need to assess whether you are actually still capable of fulfilling your responsibilities. If your schedule is already jam-packed, all you have to do is say no.
* Budget your time in advance. If you can’t take on anymore obligations don’t.
* If someone asks you to be part of a committee at the office, ask about the time input required of you and check your schedule before agreeing to join.
If you are a particularly busy person, you will probably have tons of things to do and it is perfectly natural to forget some appointments and meetings. You can avoid being late by using the alarm function on your wristwatch or your mobile device.
Set a Highly Organized Schedule
There are dozens of activities that you need to perform every single day, such as preparing to work every morning or cooking the family’s dinner at night. Organize your schedule such that these chores are clustered, giving your more time for your other tasks.
* After you make breakfast or get ready for work, take a minute and tidy up. This is so you can come home to a house and not a mess.
* After you get home from work make sure to put your things in their place. Don’t make a bigger mess for yourself. Then make sure to keep going. There is no reason to lye down before dinner.
Now implement these time management tips into your lifestyle and make the most of your life.
The Occupational Safety and Health Administration (OSHA) has issued voluntary protection program management guidelines to encourage employers to do more than just comply with regulations to prevent occupational injuries and illnesses. Although compliance with the law, including specific OSHA standards, is an important objective, an effective corporate safety program looks beyond specific requirements of law to address all hazards. It seeks to prevent injuries and illnesses, whether or not compliance is an issue.
This is precisely what some of the best workplace safety consulting firms are doing. Health and safety management system standards/guidelines are important for corporate safety and health consultants to establish. These safety management practices are compiled, applied, and finally advocated by safety and health professionals and consultants representing corporations, professional associations, and labor unions. As a result, these guidelines are used to promote workplace safety through the use of effective and comprehensive safety audits.
The health and safety management guidelines call for systematic identification, evaluation, and prevention or control of general workplace hazards, specific job hazards, and potential hazards which may arise from foreseeable conditions. Additionally, the extent to which a safety management system’s program is described in writing is less important than how effective it is in practice. As the size of a worksite or the complexity of a hazardous operation increases, however, the need for written guidance increases to ensure clear communication of policies and priorities and consistent and fair application of rules. For this reason, it is vital for organizations to seek the guidance of an industrial occupational health and safety firm. By relying on a safety organization’s expertise, a company can effectively prepare for OSHA’s Voluntary Protection Program (VPP). Since safety consulting firms conduct comprehensive audits with an emphasis on solutions-oriented recommendations for program improvement, companies become more aware of specific factors that put their employees health and safety at risk as well as the actions that need to be taken to promote a safer work environment.
Major elements of an effective occupational safety and health program include:
Management Commitment and Employee Involvement. This calls for:
“A worksite policy on safe and healthful work and working conditions clearly stated so that all personnel with responsibility at the site and personnel at other locations with responsibility for the site understand the priority of safety and health protection in relation to other organizational values.
“A clear goal for the safety and health program and objectives for meeting that goal so that all members of the organization understand the results desired and the measures planned for achieving them.
“Top management involvement in implementing the program so that all will understand that management’s commitment is serious.
Employee involvement in the structure and operation of the program and in decisions that affect their safety and health, to make full use of their insight and energy.
“Assignment of responsibilities for all aspects of the program, so that managers, supervisors, and employees in all parts of the organization know what performance is expected of them.
“Provision of adequate authority and resources to responsible parties, so that assigned responsibilities can be met.
“Holding managers, supervisors, and employees accountable for meeting their responsibilities, so that essential tasks will be performed.
“Annual reviews of program operations to evaluate their success in meeting the goal and objectives, so that deficiencies can be identified and the program and/or the objectives can be revised when the goal and objectives are not met.
Worksite Analysis. This includes:
“Identification of all hazards by conducting baseline worksite surveys for safety and health as well as periodic comprehensive update surveys. Also included would be an analysis of planned and new facilities, processes, materials, and equipment; and another of routine job hazards.
“Regular site safety and health inspections, so that new and/or previously missed failures in hazard controls are identified.
“A reliable system to encourage employees, without fear of reprisal, to notify management personnel about conditions that appear hazardous and to receive timely and appropriate responses. Investigation of accidents and “near miss” incidents, so that their causes and means for prevention are identified.
“Analysis of injury and illness trends over extended periods so that patterns with common causes can be identified and prevented.
Hazard Prevention and Control. This calls for:
“Procedures that ensure that all current and potential hazards are corrected in a timely manner through engineering techniques where appropriate; safe work practices understood and followed by all parties; provision of personal protective equipment; and administrative controls, such as reducing the duration of exposure.
Safety and Health Training. This includes training to:
“Ensure that all employees understand the hazards to which they may be exposed and how to prevent harm to themselves and others.
“Confirm that supervisors and managers understand their responsibilities and the reasons for them so they can carry out their responsibilities effectively.
The most effective workplace safety specialists help companies (internationally, nationally, and locally) continuously improve their safety management systems through comprehensive auditing where a team of highly qualified/certified safety and health professionals review the clients’ organization in terms of OSHA compliance, safety programs, training systems, etc and recommend corrective action and management process improvements as they relate to occupational safety and health.