1. PHYSIOLOGY OF TEETH
2. PHYSIOLOGY OF DENTAL PULP.
3. PHYSIOLOGY OF PARODONTIUM.
Tooth tissue form from oral mucosa (mucous membrane) that develops in the embryo. Teeth grow from tooth buds, each of which includes three components:
1) an enamel organ, which forms a multilayered epithelium of the oral cavity;
2) a dental papill, formed from mesenchyme – if fills the the enamel organ cavity;
3) dental pouch – derived of mesenchymal formation, that condenses around the enamel organ.
Stages of differentiation of tooth germ Periods of differentiation and gistogenesis
Enamel organ takes part in the formation of tooth enamel, dental papilla gives rise to the dentin and pulp, and the dental pouch – to cement and periodontium.
Tooth development is a continuous process, though it can be conditionally divided into three main periods:
1) Period of primary development of dental germs.
During this period the epithelial liningof embryos oral cavity forms a protuberance into the underlying mezenhime that looks like dental lamina (plate). New processus look like a tooth buds appear on it and subsequently form enamel organ. Mesenchyme that interacts with it – in future will transform to the dental papilla and dental sac.
2) The period of formation and differentiation of tooth germs comprising the stages of “caps” and “bell”, named according to form of the enamel organ in these stages. This period ends for temporary teeth to the end of the 4th month of fetal development. In the course of further development and growth of tooth germs they undergo differentiation and preparation formation of solid tissues – dentin and enamel.
3) Histogenesis of dental tissues is the longest: starting in the prenatal period, it expires after birth. With hard tissue dentin at first formed (dentynohenesis). After laying the first layer of dentin on the periphery of dental papilla in the epithelial enamel organ enamel begins its productio (amelohenez), over the forming dentin.
At the end of the 5th month of fetal development the process of primary dentin mineralization begins. It is possible due to odontoblasts through their processes. Formation of the organic matrix of dentin mineralization ahead its mineralisation, that is why its inner layer (predentyn) always stay nonmineralizated
Enamel – hard mineralized tissue white or slightly yellowish color that externally covers tooth crown and protects the dentin and pulp from exposure of external stimuls. Thickness of enamel is maximal in the area of tubercles posterior (chewing) teeth, where it reaches 2,3-
Enamel – the hardest tissue of the human body. It contains 95 % minerals (mainly hydroxyapatite, fluorapatite, karbonatapatyt etc.), 1,2 % of organic, 3,8 % of water. Water is coupled with crystals and organic ingredients and free. The enamel is permeable in both directions. The lowest permeability have its exterior, facing the mouth area. The degree of permeability varies in different periods of tooth development. Metabolism takes play in enamel invariably. Substances (ions) enter into the enamel from dentin and pulp, and with saliva.
At one time with the flow of ions (remineralization) their leaching (demineralization) takes play. These processes are in a state of dynamic equilibrium. Enamel does not contain cells and is unable to regenerate after damage.
Enamel is formed with enamel prisms and interpiszmatic substance. The basic structural and functional units of enamel – enamel prisms. They pass through the thickness of the enamel radially, mainly perpendicular to the enamel-dentin border, curved in the form of the letter S. S-shaped course of bundles of enamel prisms leads to the appearance of dark (diazones) and light (parazones) lines on the longitudinal sections. They are perpendicular to the enamel surface. They are called stripes of Gunther – Shreher
Enamel prisms arranged in in the form of beams, that contains 10-20 prisms. In the area of dental neck prisms are arranged horizontally. In cross section form of prisms is oval, polygonal, but more often – archoid. Enamel prisms are composed of compacted and ordered hydroxyapatite crystals.
In longitudinal sections lines of Rettsius are defined. They are brownish-yellow color, have the form of arches, that go awry from the enamel surface to the enamel-dentine border. In transverse thin sections – a concentric circles are visualisated. Lines of Rettsius – line of enamel growth, that appear because of periodicity of calcification process.
If you trace a line Rettsyus to their emergence on the surface of the tooth, they will fit circular grooves, ie parts of enamel where it has a smaller thickness. The edges of the grooves and their days are numerous small depressions on the surface of the enamel diameter of 4-6 microns and a depth of 0.5-3 microns – holes. They appear during the development and correspond to the location shoots Toms znameloblastov during completion of enamel matrix secretion.
Between these grooves are rollers height 2-
Interprismatic substance identical to the structure of the enamel prisms, but
hydroxyapatite crystals are oriented at right angles to the crystal prisms.
Interprismatic substance surrounding prisms round and polygonal forms and separates them. With arched structure prisms their parts are in direct contact with each other, and mizhpryzmova substance as such is virtually absent. Interprismatic substance in human enamel on thin sections has a very small thickness (less than 1 micron). The degree of mineralization Interprismatic matter less than enamel prisms, but higher than the shells of enamel prisms. In this regard, the decalcification in the manufacturing process of histological preparation or in vivo (under the influence of caries) dissolution of enamel occurs in the following sequence: first, in the area of membrane prisms, then Interprismatic matter and only after that same prisms. Interprismatic substance has a lower strength than the enamel prisms, so the detection of cracks in the enamel they usually pass through it without touching the prism.
Structural elements – enamel beams, plates and spindles – areas of enamel containing enough calcified enamel prisms and Interprismatic substance containing proteins (such enamelinu) at high concentrations. Enamel plates extending from the surface to the enamel – dentin yemalevo connection. They can serve as pathways of microorganisms from the surface of the enamel in depth. Enamel tufts – penetrate the enamel for a short distance. Enamel spindles – short spindle-shaped structure located in the inner third of the enamel perpendicular to the enamel- dentine border. It is believed that this spines buried odontoblasts or enameloblasty, buried in the enamel.
Enamel surface coated with a thin membrane – the cuticle, which consists of two layers:
1) primary cuticle (shell Nasmita) – internal thin (about 0.5-
2) Secondary cuticles formed by the outer thicker (blyzko10 micron) layer of reduced enamel epithelium body.
After teething cuticle rubs off on their chewing surfaces, partially keeping on the side.
Features enamel – the protective, trophic.
Dentin – calcified tissues of the tooth, which is its bulk and shape. In the area of the crown is covered with enamel, and the site root – cement. Contains 70% inorganic (hydroxyapatite), 20 % organic (collagen type I), 10% water. Dentin is composed of calcified intercellular substance, pierced dentinal tubules.
Intercellular substance formed collagen fibers associated with hydroxyapatite crystals.
The crystals are deposited in the form of grains and deep, which then merge into spherical formation – globules and kalkosferyty.
Areas hipomineralizovanoho dentin include:
interhlobulyarnyy dentin – located in the outer third of the crowns parallel enamel- dentine border. He is represented by fibrils nezvapnennymy, between which are placed globules calcified dentin.
granular layer Toms – located on the periphery
root dentin. Contains small parts slabozvapnenyh (grains) along the dentin – cement boundary.
Predentyn – internal (nezvapnenna) of the dentin adjacent to the layer of odontoblasts. Predentyn – zone growth dentin.
Identify two layers of dentin with varying swing collagen fibers
1. Bilyapulparnyy dentin – the inner layer. Dominated fibers are tangentially to the enamel- dentine border (tangential fibers or fiber Ebner).
2. Raincoat dentin – the outer, which covers bilyapulparnyy. Predominant fiber radial direction (radial fibers or fiber
Dentinal tubules – thin tubules that penetrate dentin from the pulp to the periphery. They provide trophic dentin. In dentinal tubules are processes of odontoblasts. When caries dentinal tubules with dead branches odontoblasts are pathways of microorganisms are called “dead paths.” Wall of dentinal tubules forming perytubulyarnyy dentin. Between the dentinal tubules located intertubulyarnyy dentin.
Dentin is divided into:
– Primary – formed before tooth eruption – secondary (regular, physiological) – formed after the eruption. Characterized by fewer tubes, less orderly arrangement of tubes and fibers. But these differences are insignificant. As a result of the deposition of secondary dentine of the tooth cavity is reduced in size – Tertiary (irregular, substitution, reparative) dentin formed in response to stimulation. Formed locally at the site of irritation, it is uneven and mineralized. Tubules have a wrong move or absent.
Sklerosed (clear) dentin. Formed by the deposition of dentin perytubulyarnoho in dentinal tubules, causing their narrowing and obliteration.
Features dentin: trophic, sensory, protective.
Cement – calcified tissues. Covers the roots and the neck of the tooth. His greatest thickness in the apical region. It contains 50-60% inorganic (hydroxyapatite), 30-40 % – organic (collagen).
Divided into: acellular (primary) cement – cover the middle third of the root and neck.
Does not contain cells composed of calcified intercellular substance, including densely arranged collagen fibers and the base material. Some fibers positioned longitudinally, parallel to the surface of the cement. The rest of the finer fibers (sharpiyevyh) is radially. They are sent in bundles of collagen fibers periodontium. On the other hand sharpiyevi fibers fused with radial fibers of the dentin.
Cell (secondary) cement – covering apical third of the root and root bifurcation permanent teeth. It consists of cells and intercellular substance. Intercellular matter includes fiber and bulk matter. There is permanent, but cyclical deposition of cement.
Hipertsementoz – excessive deposition of cement.
Features cement: defending, holding, reparative, passive eruption.
Pulp – loose fibrous connective tissue that fills the cavity of the tooth. It consists of cells and intercellular substances. Cells – odontoblasts, fibroblasts, to a lesser extent – macrophages, dendritic cells, lymphocytes, plasma and mast cells, eosinophilic granulocytes. Odontoblasts – pear-shaped cells in the coronal pulp, cube – in the root. They produce dentin. Processes – fibers Toms – walk in dentin. Fibroblasts – the most numerous cells. Intercellular substance – actually collagen and reticular fibers embedded in the base material. In the temporary teeth pulp has about the same histological structure throughout, while the permanent crown is divided into root and.
Coronal pulp – loose, vascularized and many inervovana connective tissue with many cells. Odontoblasts are arranged in several rows. Root – contains more fiber, more dense, less vascularized and inervovana, its cellular composition is less diverse.
In the pulp distinguish three cell layers:
1) Peripheral – compact layer of odontoblasts in 1 – 8 rows;
2) Intermediate (subodontoblastychnyy) has 2 zones:
– External (zone of Weil) – besklitynnyy layer Poor cells. Includes processes of cells of the inner zone, nerve plexus Rashkova, blood capillaries;
– Internal (cell rich cells) contains fibroblasts, undifferentiated klitynyky, preodontoblasty, capillaries, and bezmiyelinovi myelin fibers;
3) the central layer is formed by loose fibrous tissue containing fibroblasts, macrophages, larger vessels, bundles of nerve fibers.
Blood vessels and nerves enter the pulp through the apical opening. Arterioles in the channel giving lateral branching to the layer of odontoblasts, their caliber is reduced. In crown arcade arterioles form from which originate the smaller vessels. In the coronal pulp identify all elements of the microvasculature and anastomoses.
In the pulp is contained lymphatics (lymph flow through the upper jaw mandibular opening to submandibular nodes on the lower jaw – the deep lymph nodes internal jugular vein).
Bundles of nerve fibers outside the neurovascular bundle. Subodontoblastychnye nerve plexus (Rashkova) is located inward from the layer of odontoblasts. Pulp fibers and mielynovi bezmiyelinovi.
In the pulp can be formed dentykli and petrificates. Petrificates – diffuse areas of calcification. Dentykli – local calcification, the formation of round or irregular shape, consisting of dentin (highly organized) or dentynopodibnoyi tissue (nyzkoorhanizovani). First formed odontoblasts, the second – undifferentiated cells. There are free (are surrounded pulp), parietal (facing the wall), interstitial (buried in dentin).
Blood vessels and nerves enter the pulp through the apical opening. Arterioles in the channel giving lateral branching to the layer of odontoblasts, their caliber is reduced. In crown arcade arterioles form from which originate the smaller vessels. In the coronal pulp identify all elements of the microvasculature and anastomoses.
In the pulp is contained lymphatics (lymph flow through the upper jaw mandibular opening to submandibular nodes on the lower jaw – the deep lymph nodes internal jugular vein).
Bundles of nerve fibers outside the neurovascular bundle. Subodontoblastychnye nerve plexus (Rashkova) is located inward from the layer of odontoblasts. Pulp fibers and mielynovi bezmiyelinovi.
In the pulp can be formed dentykli and petrificates. Petrificates – diffuse areas of calcification. Dentykli – local calcification, the formation of round or irregular shape, consisting of dentin (highly organized) or dentynopodibnoyi tissue (nyzkoorhanizovani). First formed odontoblasts, the second – undifferentiated cells. There are free (are surrounded pulp), parietal (facing the wall), interstitial (buried in dentin).
Features pulp: plastic, trophic, sensory, protective and reparative.
Despite the fact that the development of temporary and permanent teeth runs the same type, they have a number of features, both at various stages of their development, and at the end of the latter. Differences between fully formed temporary and permanent teeth regarding how anatomical features and their microscopic structure.
Teeth – solid bodies that provide chewing food. They also neohidni to process speech and perform certain aesthetic function. Roptashovuyutcya teeth in the mouth and cover about 20% of its surface. In distinction tooth crown, root, part of which is placed in the hole (alveoli) of the jaw and the neck of the tooth – the place go to the root crown. Inside the tooth is a cavity, which is divided into coronal and root canals, and in the area of apex apical end (apical) hole. Place switch in the coronal channels called root canal mouth. Placed in the cavity of the tooth pulp of the tooth.
Crowns teeth have 5 surfaces:
1. Vestibular who returned to peredstinku mouth. In front teeth, it is called the lip, the lateral teeth – Jaw.
2. Oral, which is paid to the actual mouth. Crowns teeth have 5 surfaces:
1. Vestibular who returned to peredstinku mouth. In front teeth, it is called the lip, the lateral teeth – Jaw.
2. Oral, which is paid to the actual mouth. In the teeth of the mandible is also called the language in the teeth of the upper jaw – palate.
3. Aproksymalni or contact – a side surface of the teeth. This front surface faces the midline, called the medial and posterior – lateral or distal.
4. Chewing.
The man developed two generations of teeth – temporary and permanent. This phenomenon is obviously related to the adaptation of the size and number of teeth the size of the jaws. Because of small jaws develop small teeth initially with a reduced number, and only later, with the growth of the jaws, they formed larger in more teeth, size and function of your teeth are in accordance with the size of the jaws. Milk or deciduous teeth, there are 20, and regular – 32.
The form and function are 4 groups of teeth:
1. Cutters – front teeth, 4 on each jaw. Their function is to nibble food.
2. Fangs – 2 on each jaw, serving for separation of food.
3. Premolars –
4. Molars – 6 teeth on each jaw in permanent occlusion and in 4 – in milk. Designed for crushing and grinding food.
The order of the tooth appears dental formula.
The clinic dental formula of permanent occlusion written in Arabic, and dairy – Romaumerals:
The horizontal line indicates a tooth belonging to the upper or lower jaw, and the vertical – to the right or left side.
Teeth that erupted, taking the specified position in the jaw, have a number of grounds on which you can install them belong to the respective jaw and side (right or left).
The main features of the three:
1) signs of crown angle;
2) The sign of the curvature of the crown;
3) The sign of the deviation root
The sign of corner crown angle – crown formed by the medial- aproksymalnoyu surface and cutting edge sharper than the angle formed by the distal- aproksymalnoyu surface and a cutting edge. Most clearly marked sign is found in the central and lateral incisors and premolars of the upper jaw.
The sign e of xpressed crown curvature – is the most convex part of the vestibular (labial, buccal) surface of the tooth crown is closer to medial- aproksymalnoyi surface. This feature is more pronounced when considering the tooth from the occlusal surface or cutting edge.
The sign of root deviation is the root of all distortion or its apex in relation to the longitudinal axis of teeth: incisors and canines in the lateral direction, and the premolars and molars – in the back.
This sign is taken into account in the process of expanding impassable root canal and the disclosure of top hole tooth.
The upper jaw of 21 12 more pronounced signs of angle and curvature crown and root trait deviation expressed slightly, all three features are expressed well in 43 34 and 5 5 more weakly, in the June 7 June 7 distinct signs of curvature crown and root deviation, but only slightly – a sign of the angle.
The lower jaw angle feature in the central incisors absent, and in lateral incisors is weak, signs of curvature crown and root deviation is almost not expressed, in canines distinct hallmark of all three, the first premolars are elongated New sign of curvature crown and root sign of rejection, sign of the angle is not expressed in the second premolar tooth identities are mild, and the first and second molars explicit signs of curvature crown and root deviation.
Central incisor. Tooth dolotopodibnyy. Vestibular surface of the crown is slightly convex. For midline longitudinal ridge is. Cutting edge slightly oblique lateral and medial has a sharp angle. At the cutting edge are three mounds. The root of a well- developed, conical. On cross- sawing oval. In general, oral tooth shape replicates the shape of the crown and root of the tooth.
Lateral incisor. Crown dolotopodibna, cutting edge due to a pronounced medial angle resembles hump. Vestibular surface of the crown is convex. Concave lingual surface of the crown facets is limited. The side bolsters are often converge in the cervical region, forming a triangle on top of which is a recess (blind hole). The root has a strong splyuschenist in mediolateralnom direction. The cavity of the tooth corresponding to the reduced form of the crown and root. As the central incisor, tubercle cutting surface of the cavity of the tooth pulp horns to match three of which expressed the medial better.
Fang. A tooth is angled position in the jaw. Vestibular surface of the crown is convex. On the lingual surface is elongated ridge that separates the two crown facet, from which lateral larger area. Longitudinal enamel surfaces of both rollers move in cutting crown hump. The side faces forming a crown of cutting edge two angles from which a medial stupid. In a canine cone-shaped straight root. At the root of the transverse sawing round or slightly oval. Root fangs slightly compressed laterally, resulting iarrowed orifice root canal. The cavity of the tooth contour crown and root. In the dentin of the tooth crown, according to projections tubercle is cutting pulp horn.
The first premolar. Crown prismatic shape, buccal and lingual surfaces whose convex. On chewing surfaces of two bumps – buccal and lingual, from whom much more. Between the tubercles in perednozadnomu held in grooves that are not reaching the edges, interrupted by small enamel ridges. The crown of the tooth in cross sawing has an elongated oval shape with the largest transverse dimension in the buccal-lingual direction. Root flattened, often divided into buccal and lingual (the latter pronounced better) and contains the appropriate root canals.
Second premolar. Crown prismatic shape. On chewing surfaces, there are two hillocks, from which developed buccal better. Tubercles separated by a transverse groove that runs along the center of the chewing surface and separated from the crown facets small enamel ridges. Jaw area greater than the lingual crown. Root often one conical, straight, compressed in the anteroposterior direction, containing one root canal. Sometimes (in 15% of cases) closer to the top there is a split root. In 25 % of the tooth contains two root canals (buccal and lingual).
First molar. Crown is rectangular in shape, the diamond-shaped chewing surface 4 tubercles, two pagan and two more the advanced cheek. Tubercles separated H -shaped fissures. In the area perednoyazykovoho curved tubercle sulcus separates the light that does not reach the occlusal surface, an additional hump. According to the humps on the chewing surface of the tooth in the oral cavity to have four horns of the pulp. Burying on the buccal side more pronounced. The roots of three. Massive palate, round and straight, the other two shorter – cheek (front and rear), flattened laterally, posteriorly rejected. Perednoschichnyy roots developed better.
Second molar. Cube-shaped crown at 4 zhuvatelniy surface hillocks separated by X -shaped fissures. Jaw tubercles developed better language. The number and arrangement of tubercles fissures can be in various forms. A tooth has three roots. Palatine largest, straight, good passing. Both Jaw – front and back – flattened, with a broad-based, rejected in the anteroposterior direction. The front can have multiple root canals and apical openings.
The third molar. By building the third molar is like the second molar and can have a variety of options as to size, shape and number of crown roots. The number of humps and location of fissures on the chewing surface is different. Tooth has a tendency to reduction, and therefore its germ is sometimes absent. The roots are often fused together in one massive short barrel. Form tooth cavity and the number of root canals may not match the outline of the tooth.
TERMS OF ERUPTION AND RESORPTION OF ROOTS
Teething is a person in a particular sequence, and set the average time of eruption of each tooth, taking into account their small natural variations in either direction. Only the sharp differences in time of eruption of these terms should be considered as an anomaly. Terms teething in children is a measure of overall physical development. First appear in the mouth temporary lower central incisors. This is a child in the 6th month, then immediately cut through the lower side and the upper central incisors (7 month). Other deciduous teeth erupt between the 16th and 30th months (Table 1). They operate over the next four years and begin to fall on the 6th year.
Stage temporary tooth root formation can express abstract formula 2 +2 +2 as full root dentin formation is completed only after the eruption of teeth: the teeth this time period is approximately 1.5-2 years. After completion of the root apex moves past the stage of stabilization, which also takes an average of 2 years. The next step in the evolution of deciduous teeth root resorption is a period, lasting on average and is 2 years.
Average time of eruption and loss of deciduous teeth
(by E. Borowski et al, 1989 and Carlson BM, 1994).
|
Upper |
Date of Eruption(in months) |
Date of Loss (in months) |
|
Central incisor 7 mths |
6-8 |
6-7 |
|
Lateral incisor 8 mths |
8-12 |
7-8 |
|
Canine 16-20 mths |
14-20 |
10-12 |
|
First molar 12-16 mths |
12-16 |
9-11 |
|
Second molar 21-30 mths |
20-30 |
10-12 |
|
Lower |
|
|
|
Central incisor 6 1/2 mths |
|
|
|
Lateral incisor 7 mths |
|
|
|
Canine 16-20 mths |
|
|
|
First molar 12-16 mths |
|
|
|
Second molar 21-30 mths |
|
|
It takes 6-8 months, during which the jaws are rebuilt and infants are able to perceive a new factor – teething. Temporary teeth, the beginnings of which are in the alveolar process of the jaws, are vnutrishnoschelepnoho certain stages of development, gradually cut through, forming a temporary occlusion of the teeth.
The formula for permanent teeth WHO
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Formula milk teeth by WHO
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75
Temporary occlusion divided into three periods: 1 – the period of formation (from 6 months to 2-2.5 years) 2 – stable period of temporary occlusion (2.5 to 4 years) C – from aging or signs of abrasion, late temporary occlusion (4 to 6 years).
Replacement bite – a higher degree of development and differentiation of teeth- jaw system. It is characterized by the presence of jaw bones both a temporary and permanent teeth. Duration of the change of teeth varies from 6 to 12-14 years.
Alternating occlusion divided into two periods: I (early) – from 6 to 9 and II (late) – 10 to 12-14 years.
I – is characterized by the eruption of the first permanent molars and incisors change,
II – eruption of premolars and second molars, canines change.
In alternating occlusion ongoing root resorption of deciduous teeth, so they are moving. Terms of eruption of permanent teeth depends on the general condition of the body, and the conditions of life, of the deciduous teeth and their periodontal since their premature removal, and so on.
Eruption of the first permanent molars II provides a physiological rise heights bite. Forming and tranverzalna sagittal occlusal curves.
In alternating occlusion are two periods of most intensive growth of the jaws, And – which precedes and accompanies the eruption of the first permanent molars; II – meets the eruption of premolars and second molars and canines change.
Development of permanent teeth in general resembles the development time. The source of tabs forming enamel of permanent teeth as temporary, is a dental plate. Bookmarks that give rise to permanent teeth, which are replaced (permanent incisors, fangs and premolars), resulting from enhanced cell proliferation of dental lamina near the enamel of deciduous teeth and its expansion as a replacement tooth plate, (successional dental lamina – in English literature). As a result of the growth of the dental lamina formed epithelial Bookmarks permanent teeth that interact with ektomezenhimoyu. They are located on the lingual side of deciduous teeth. Their subsequent development does not differ from that of deciduous teeth, but proceeds more slowly. The beginnings of permanent teeth initially located in one of alveoli with time, but later they are completely surrounded by bone tissue.
In permanent molars time no predecessors, so they are called complementary. Initial development of teeth differs from that described above. In the growing fetus jaws on the 5th month of tooth plate goes under the epithelium that lines the mouth behind the temporary molars developing countries. From this originated epithelial ingrowth bookmarks with mesenchyme forming the beginnings of the first, second and third permanent molars. In some cases, the tooth plate material is consumed before it reaches the site of formation bookmarks third molar enamel organ. As a result, these teeth will not grow. As the enamel organs do not develop permanent molars of substitution, and the ” parent ” dental plate, which gives rise to enamel organs of deciduous teeth, it is suggested that these teeth embryological be attributed to the generation of temporary rather than permanent. Thus, the development of permanent and deciduous teeth occurs same type but at different times. At a time when deciduous teeth are the last stage of its development, the jaws are favorites permanent teeth that are at earlier stages of development. Therefore, in the period from 3 to 6.7 years in both jaws can be found from 48 to 52 teeth. 20 of them (deciduous teeth) has completed development and perform its function, while others are still in various stages of development. Development of permanent teeth is slower than temporary. For example, during the growth of temporary incisors as a whole is about 2 years old, and the time – about 10 years.
During the eruption of permanent teeth, as the rapid vertical movement of the tooth, it is putting pressure on the alveolar bone, resulting in differentiated osteoblasts, which actively included in the process of bone resorption. However, to date there is no consensus on the process of teething, but instead suggested a significant number of theories explaining the mechanisms of teething. The greatest attention should be four of them, in which the main mechanisms include: 1) the growth of the tooth root, and 2) increased hydrostatic pressure in peryapikalniy zone or the pulp of the tooth, and 3) alteration of bone tissue, and 4) periodontal craving.
1) The theory of the growth of the tooth root is based on the notion that the root of which is extended, rests on the bottom of the bladder and causes the appearance of strength that pushes the tooth vertically. This theory encounters a number of serious objections. Thus, it is established that some teeth eruption in doing a path length much larger than the size of their roots. Moreover, the pressure of the top to the bottom of the alveoli inevitably causes bone resorption, due to which it is unable to provide a supporting function.
Since the beginning of root formation is the formation of periodontium. According to X-ray distinguish 5 stages of root formation of permanent teeth:
1. Immature root.
2. Emerging elite.
3. Uncovered apical opening.
4. Emerging periodontium.
5. End forming roots and periodontium.
The root of the tooth that is formed has different lengths at different ages and projected on the radiograph as two parallel bands of light that starting from the crown, gradually tapering and ending two spines. Root canal during this period gradually increasing iyapryamku apex of the tooth and looks like a delivery mouth. Channel in the lower portion merges with the sharp enlightenment rounded. This is not nothing but a projection located at the apex of the emerging root rostkovoyi zone. It decreases as the root formation and disappears under the emerging elite, but instead some time been extended periodontal gap.
2) The theory of hydrostatic pressure exists in two versions. According to the first eruption of teeth occurs due to increased pressure in the interstitial fluid peryapikalniy root zone. This creates a force that pushes the tooth in the mouth. The reason for increasing hydrostatic pressure, most researchers see in enhancing local blood supply peryapikalnoyi zone during development. Proponents of this option are indirect evidence that a tooth make oscillatory movements in the dental alveoli by pulse wave. However, surgical removal of the root is formed, together with the surrounding tissue and blood vessels does not prevent eruption.
Increasing peryapikalnoho hydrostatic pressure may be associated with increased vascular permeability, causing fluid accumulation between the bottom tip of the alveoli and roots. The main carrier fluid with a basic substance having high hydrophilicity. Accumulation of tissue fluid, keeping squirrels at the root of the tooth, which erupt repeatedly identified in histological preparations.
According to the second variant of the theory of hydrostatic pressure, the pulp of the tooth that is caused by differentiation of dental papilla, dramatically increases in volume, particularly in the area of its top, creating pressure inside the tooth germ. This last, like a rocket, moves to the free edge of the gums. From these positions forming the root is not the cause but the consequence of tooth eruption.
3) The theory of reconstruction of bone tissue suggests that the eruption is caused by a combination of selective deposition and resorption of bone tissue in the wall of the alveoli. It is based on observations of nature restructuring alveoli accompanying the eruption. It is assumed, in particular, the growth of bone at the bottom of the alveoli tooth pushes toward the mouth. However, consider that the formation and resorption of bone around the tooth root that cuts through a consequence, not the cause of his eruption. Moreover, the eruption of some teeth between the apical part of the root and the bottom of the alveoli remains considerable distance.
4) Theory of periodontal traction in recent years has received widespread. According to its main provisions of periodontal formation is the main mechanism for providing the eruption of the tooth. According to one version of this theory, the thrust caused by periodontal collagen synthesis, which is accompanied by shortening of bundles of fibers. Another option indicates the contractile activity of fibroblasts (myofibroblasts) periodontal as the driving mechanism of eruption (similar to the mechanism of reduction of wound that heals, under myofibroblasts). Contractile myofibroblasts periodontal individual efforts are combined intercellular connections due to availability and passing on the collagen fibers are converted into traction, providing eruption. Suggested that the draft could not be created due to the reduction of fibroblasts, resulting in their migration. A necessary condition for the proper application of traction in this version of this hypothesis, like the previous one, is oblique arrangement periodontal fibers. Violation of or damage to periodontal tooth eruption stops.
The existence of multiple theories teething, briefly discussed above, a whole clearly indicates that no single universal theory. However, the arrangements made by various theories are not necessarily mutually exclusive – teething can be a multifactorial process in which the combined effect of several mechanisms. Permanent teeth erupt in the following terms:
Average time of eruption of permanent teeth
(by E. Borowski et al, 1989 and Carlson BM, 1994).
|
Name of tooth |
eruption terms, years |
|
|
Central incisors Side cutters Fangs First premolars Second premolars First molars Second molars
|
7-8 8-9 12-13 9-11 11-12 6-7 12-13
|
10-11 11-12 15 12-13 13-14 10 15
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In addition to teething in the appropriate time (timeliness), physiological dentition characterized by other features. They are:
1) the sequence of eruption – eruption of teeth in a certain order (first molars – central incisors – side cutters – first premolars – second premolars – fangs – second molars) given they belong to the upper or lower jaw (probably erupt teeth on the lower jaw with the exception of the lateral incisors);
2) symmetrical eruption – teeth erupt simultaneously on the left and right side of the jaw;
3) parity eruption – eruption under the same title at the same time groups of teeth on the upper and lower jaws.
Permanent teeth are different from the time the following features:
1. Height of permanent teeth more.
2. Permanent teeth have a yellowish tint as opposed to bluish- white in time.
3. Permanent teeth are in the dental arch angle, and temporary – vertykalno.Verhni teeth coronal tilt forward (vestibular) and root -back (oral), lower – on the contrary: crowns tilted oral and roots – vestibular.
8. Number of permanent teeth bite – 28-32 and temporary – 20.
In the development of the jaw bones, especially their alveolar processes, is essential to the balance of antagonistic muscles (which raise and lower jaw, shifting it forward and back, left and right).
An important role in this process is played by facial muscles and muscles of the tongue. If the muscles of the tongue is like a stimulator of the jaw bone, the facial muscles act as their antagonists.
Due to changes in the shape and function of the temporomandibular joint changes the structure and relationship of the dental arches. If temporary occlusion occlusal surface (chewing) is horizontal, then the variable compensation occlusal bite shaped curves – sagittal and transversal their severity depends on the articular tubercle. Sagittal occlusal curve provides contact alignments during movement of the mandible forward at least 3 points are arranged in a triangle with the basics for the tip on the molars and front teeth. The three contact points are trypunktovym contact Bonvilya. Sagittal occlusal curve formed by 10-12 years.
Along with sagittal formed transversal occlusal curve that provides contact alignments during the transversal (lateral) movements of the mandible. The proper understanding of the growth of the dental arches and skeleton face during the change of teeth is necessary to consider the fact that before the permanent teeth eruption jaws are in close position. Changing the teeth occurs in two stages. For 1 (initial) phase is characterized by increase in the size of the sum of the anterior dentition segment as the total value of the size of the lower permanent teeth more than temporary, an average of
On the tooth that cut through to affect the growth of the jaws, the pressure of the muscles of lips, cheeks and tongue, inclined planes hills crowns of teeth -antagonists. During this period, a significant increase in bone observed in the region of the rear edges of the branches of the lower jaw, and in the frontal area and the external surface of the body of the mandible. Extending the labial arch due to increase bone needed for distribution and zstanovlennya permanent incisors in the dental row, since only very rarely enough jaw growth in width. This sagittal height determined in two different parts of the jaw and at different times – due to the eruption of the first permanent molars, and permanent incisors and canines. Proper dental sagittal relationship is possible if growth under the influence of mandibular dentition is moved medially, not ztrachayuchy contact with the upper tooth row. Therefore, partial eruption of the first permanent molars leads to malocclusion not only in vertical but also in ahitalnomu direction.
II period alternating occlusion (closing, late): starts from ’10 II during the change of teeth, when 18-20 months 12 deciduous teeth are replaced by permanent. First, there is the eruption of upper first premolars and lower canines (9-10,5 years), then 10,5-12 years – second premolars and canines in the upper jaw, the lower second premolars and second permanent molars with no time predecessors.
In II period variable bite again observed active growth zuboalveolyarne arches, which mainly depends on the formation of roots of permanent canines and premolars.
To change the teeth on the upper and lower jaw are different. The upper jaw first premolars erupt first, then canines and second premolars (often simultaneously). As compared with the lower jaw remaining space is eliminated not only by mesial displacement of upper first permanent molars as a result of distal movement of the upper canines erupt that, and distal slope under pressure from their first permanent molars.
The lower jaw fangs are replaced first, then first, followed by the second premolars. Therefore, during the eruption of the lower canines caot deviate distally, after replacing the temporary molars premolars lower permanent lateral teeth can zsuvatysya more forward than the upper, which ensures correct bite.
During the eruption of permanent teeth is the development of dentitioot only horizontally but also vertically. It tops the roots of teeth that erupt, rise relative basis jaw. This is especially seen in the area of canines when apical base, part of the alveolar process that covers the top of the roots are moved to the occlusal direction. Often place a permanent fangs created during the third pulse in the sagittal growth of the jaws and transverzalnomu directions. Thus, III physiological increase occlusion associated with eruption of the canines, not second permanent molars (FY Horoshylkina, 1987).
During the eruption of permanent teeth determine the significant increase in tooth- alveolar arch in the sagittal and transverzalnomu areas, which increases the distance between the permanent teeth. After that permanent occlusion of significant changes in the size zuboalveolyarnoiyi curves do not show. Especially remains stable ¬ etsya distance between the lower canines.
The growth of the jaws during the change of teeth due to three factors: Factor I – biological growth tendencies; II factor – the eruption of permanent teeth; III factor – the normal function of the masticatory muscles, which is full of permanent occlusion.
The value of human dentition due to its features – closing of the lips, chewing, swallowing, breathing, movotvorennya. Therefore dentition system should be considered as a functional system in relation to its morphological development, improvement and differentiation of functions that occur in the postnatal period before and after the eruption of teeth and the formation of dentition. It is necessary to highlight periods when the morphological status of the masticatory apparatus meets its functional purpose.
1 period – from birth to 1 year, corresponding to infancy and is characterized by the most intensive formation of motor skills. The child is dominated by reflex sucking movements. Features regulate various physiological pro ¬ cesses perform intermediate and midbrain, but already in the first days of life are beginning to emerge reflexes, primarily related to an act of power. The child gradually masters the simplest locomotor functions.
2 period – from 1 to 6 years old when, along with unconditional sucking reflex due to the eruption of deciduous teeth and dentition formation is the formation of conditional reflex chewing movements. Initially, the child learns to chew, barely chewing food, but in 3 years has generated stable rhythmic chewing movements. Well developed skill goes into automatism. In the motor development of the child should be divided into two interrelated trends: the complexity of motor reactions and decay, the reduction of a number of congenital unconditioned reflexes. Morphological development of the dentition contributes to the further development of the functions of the mouth.
3 time (from 6 to 12-13 years) is characterized by a change in bite. During this period, under conditions of physiological eruption of permanent teeth and jaw development is further differentiation of functions and improve chewing automatism
4 time – corresponds to the permanent occlusion. Normally this period manifest a complete morphological development of tooth- jaw system and the formation povnotsin ¬ tion functional system. The forming of physiological dynamic stereotype chewing. Habitual chewing movements occur mechanically, mostly on a subconscious level. Motor automatism ensures the most economical expenditure of muscular energy during chewing. This period may be of varying lengths, which is primarily due to the condition of the teeth- jaw system.
Periodontium – Complex tissues surrounding the tooth and have genetic and functional commonality: periodontal bone alveoli, clear of periosteum and tissues.
Gums is part of periodontal diseases. Marginal gingival margin located in the cervical area of the tooth mezhoyu which is the level of the crest of the alveolar ridge. Separately, in the area isolated interdental papilla, as is often develops inflammation. Called alveolar portion of ash that covers the alveolar sprout. This division gum handy in the clinic for precise localization indicate pathological changes. At the turn of marginal (free) and attached parts gum is yasennyyzholobok that inflammation and disappears with age. Clear is part of periodontal this mucosa that covers the alveolar bone of the upper and lower jaws. The clinic distinguish marginal (free) and alveolar (attached) of the gums. Marginal part is located in the cervical area of the tooth.
Gums consist of actual mucosa and epithelium. In all areas, except for gingival papilla of the upper jaw, gums have submucosal layer and directly connected with the periosteum of the alveolar ridge of the jaw.
Gums coated stratified squamous epithelium consisting of basal and ribbed layer. In 50 % of cases orohovivaye epithelium, and then appears granular layer containing grains keratogialina. In 40 % of cases iormal gingival epithelium observed in parakeratosis – a condition in which the surface epithelial cells ribbed sharuuschilnyuyutsya influenced by mechanical impact and retain the core.
Keratosis should be seen as the ability to perform gum protective function in response to mechanical pressure food and more.
Gingival epithelium has a high mitotic activity of cells containing a large amount of RNA in the cytoplasm of basal cells and ribbed layers. This indicates a high level of metabolism, which is the basis for regeneration.
In the intercellular substance is a glycosaminoglycan that serve a protective function in the event of exposure of bacteria and their toxins. The cytoplasm of cells of the basal epithelium and ribbed gum contains large amounts of RNA. These cells have a high mitotic activity and is the basis for regeneration. In the cells of the basal layer ob ¬ rihayetsya high activity of succinate dehydrogenase and ribbed layer – lactate dehydrogenase.
For histological structure of gum epithelium is composed of three distinct areas: oral (mouth), gums lining the outside sulkulyarnoyi (grooved) and connective (tion attached epithelial) cells which are connected via an organic matrix of enamel apatite crystals. Gingival sulcus epithelium continues in connecting. Grooved coupling epithelium and not zrohovivaye and unlike oral can easily updatable, and he characterized as increased permeability due to the proximity of blood vessels. Sulkulyarnyy gingival epithelium localized in the cervical area of the tooth and lining the gingival sulcus. It is not so easy zrohovivaye piddayet
Xia microorganisms and their toxins, microbial enzymes.
Iormal epithelial cells do not contain glycogen. When inflammation occurs in the cells of glycogen deposition layer ribbed gum in breach keratolizatsiyi epithelium. Between the epithelial cells are glycosaminoglycans – cementing substance for epithelial cells, that the action of bacteria and toxins is protective.
In the area of free (marginal) land of the gums is important anatomical education – clinical gingival crease (periodontal gap), circular ligament of the tooth top mizhkoronkovyh alveolar walls and partitions.
Clinical gingival crease (orifices) located between healthy gums and tooth surface, it appears prudent for probing and always deeper than anatomic crease, according to some authors, its depth is 1-
Sulcus epithelium epithelium and connective tissue protect against periodontal pathogenic action of various factors, disorders of communication connecting with enamel epithelium leads to changes in protective properties, and subsequently to the formation of periodontal pockets.
Gingival borozda – the main strategic area where initial symptoms appear periodontal disease. Connecting epithelium is a barrier protection for all periodontal tissues on the outside of the part of the mouth. It is insightful and it goes through the constant movement of biological agents in the two sides. On the part of the cavity rotazdiysnyuyetsya tsentrostrimka diffusion of metabolites of dental plaque (toxins, enzymes, antigens, mitogens, hematoksychnoho factor). At the same binder in the epithelium of the movement of cells deeper layers of the epithelium in a binder surface layers and outside of the fabric. Movement of dead epithelial cells in the gingival grooves and replace them with new ones is one of the adaptive mechanisms that promote continuous renewal of the epithelium.
At the time, an increase in microbial attack polinukleariv of periodontal deep layers of the epithelium and connecting through it in the gingival grooves, about the amount of one million for the first minute, which is the earliest protective barrier fabric.
In the process of life connecting epithelium is constantly updated with why this is happening at a faster pace than in the cells of the outer layer of the epithelium of the oral cavity.
Gum crease and gingival fluid iormal barrier function to perform pidlezhachyh periodontal tissues. Integrity borizdkovoho and binder epithelium provides zahystmikroorhanizmiv, their toxins and others. Found that gum disease begins with borizdkovoho epidermal and epithelial attachment.
In the gingival sulcus due to increased permeability of these vessels krovonos ¬ fluid accumulates, which is close in composition to blood plasma and contains electrolytes, enzymes and cells. And the gingival sulcus and gingival fluid barrier function for performing periodontal.
Actually gingival mucosa presented loose connective tissue (papillary layer) directly beneath the epithelium and a dense connective tissue in the deeper parts of the gums (reticular layer). It consists of a core (interstitial) substances and fibrous structures
cellular elements. In it are blood and lymph vessels, nerve elements are placed.
Among the cellular elements of the connective tissue gingival fibroblasts are more common, at least – histiocytes and lymphocytes, even less – mast and plasma cells. Mast cells iormal gums are grouped mainly around blood vessels in the papillary layer of its own shell. In mast cells contain heparin, histamine and serotonin.
Fibroblasts synthesize collagen and mukoproteyidy containing hialurynovu acid and hondroetynsulfat. Mast cells produce heparin, histamine. Lymphoid and plasma cells produce antibodies, thereby taking part in the humoral and cellular immune response.
The basis of their own gums mucosa are bundles of collagen fibers. Elastic fibers are located in the papillae of the gums, argyrophil fibers form pidepitelialnu membrane.
Around the neck of the tooth collagen fibers form a circular (circular) connection.
In many gums arterioles, capillaries, venules, which support normal metabolism of tissue, numerous nerve endings in the form of loops, glomeruli, Meissner corpuscles.
Periodontal – a unique range of fabric placed between the compact plate alveoli walls and cement root. The fabric can be attributed to periodontal varieties decorated connective tissue. Periodontal different from the dense connective tissue of a variety of cellular elements, it consists of voloknystyhstruktur layers of loose connective tissue, which are nerve fibers, blood and lymph vessels. Periodontal slit width from 0.15 to
Slit width of periodontal
The basis of the fibrous periodontal structures are collagen, oksytalanovi, flexible, argyrophil fibers. Feature cellular structure with the presence of periodontal osteoblasts and tsementoblastiv. These cells are responsible for the structure of the bone cement alveoli and tooth root.
Fibrous structure of the marginal periodontium together form a circular communication tooth. In marginal periodontal fiber bundles are 14 that go in different directions.
Bone tissue alveolar process on the structure and chemical composition does not differ from other parts of bone skeleton.
Bone tissue alveolar bone consists of spongy substance. Compact material is located on the oral and vestibular (vestibular) surface of the tooth root and consists of perekladok bone (trabeculae). Between the plates is spongy substance of bone formed mesh perekladok. Bone and brain cavity filled with bone marrow. Compact material as well as the sponge, thoroughly imbued with blood vessels and nerves, has a close relationship with all the constituent elements through periodontal periodontal collagen fibers.
The structure of the base of the bone tissue is protein – collagen with lots of hydroxyproline and fosfoserynu, citric acid.
Glycoproteins containing bone hondroyitynsulfat, hyaluronic acid and kreatynsulfat.
60 – 70% is made up of minerals and a small amount of water for 30 – 40% – of organic matter, which is a major component of collagen.
Operation of bone is mainly determined by the activity of cells: osteoblasts, osteocytes and osteoclasts,
Iormal adults in the process of formation and bone resorption equilibrated. This ratio depends on the activity of hormones, primarily by parathyroid hormone.
Blood supply. Periodontal tissues krovonapovnyuyutsya arterial blood pool of the external carotid artery and its branch jaw artery. Teeth and surrounding tissues of the upper jaw receive blood from the upper alary (upper lunochkova artery) and klynopidnebinnoyi (upper front lune artery) Parts jaw artery. Teeth and surrounding tissues of the mandible are supplied with blood mainly from the lower lunochkovoyi artery.
From the inferior alveolar artery to each interalveolar septum away one or more branches – mezhalveolyarnoy artery that branches to give periodonhu and cement root.
Speaking of the structural formation of microvasculature periodontal tissues should be aware arteries, arterioles, prekapilyary, capillaries, postkapilyary, venules, veins and arteriolovenulyarni anastomoses.
Capillaries and the surrounding connective tissue with lymph supply power to periodontal tissues and serve a protective function. The degree of capillary permeability and stability is of great importance in the development of pathological processes in periodontal tissues.
Periodontal innervations.
Implemented by twigs area plexus second and third branches of the trigeminal nerve. At the bottom of the alveoli bundles of nerve fibers are divided into two parts: one goes to the pulp, periodontal second surface parallel to the maierve trunks pulp. The large number of nerve receptors suggests extensive periodontal reflex zone.
Lymphatic vessels.
In the periodontal is an extensive network of lymphatic vessels, which play an important role in the functioning periodontal disease, especially in its diseases. When inflammation of the lymphatic vessels dilated and promote, its remove interstitial material from the lesion.
Functions of periodontal.
Periodontal performs the following functions: barrier, trophic, reflex regulation chewing pressure, plastic and shock absorbing.
Periodontal barrier function is determined by:
1) the ability of the epithelium to the gingival keratinization (inflammatory diseases, this ability is broken);
2) structural features and functions of gingival bits;
3) a lot of features and bundles of collagen fibers directly;
4) presence of mast and plasma cells, which play an important role in the production of antibodies;
5) tension gums;
6) state entities periodontal connective tissue glycosaminoglycans;
7) antibacterial function of saliva is the presence in it of biological substances such as lysozyme, etc.
Trophic function caused by the widely ramified net of capillaries and nerve receptors. This feature is in many respects depends on the preservation or restoration of normal microcirculation in the functioning periodontal disease.
Reflex regulation chewing pressure is due to many many nerve endings (receptors) that are in the periodontium. Due to the existence of periodontal muscular reflex regulated power cuts chewing muscles, depending on the nature of the food of periodontal receptors.
Plastic periodontal feature is its constant renewal of tissues that are lost during physiological and pathological processes. To carry out this function of tsementoblasts, fibroblasts. It plays a role as the state of trans exchange.
Shock-absorbing function is performed by collagen and elastic fibers. Рeriodontalnal ligament tissue protects the dental alveoli, blood vessels and nerves of the periodontal injury.
Periodontal constantly exposed to environmental factors and internal factors. Sometimes the action is so strong that periodontal tissue are too large overload. However, their destruction does not occur. This indicates significant adaptive capacity periodontal disease. All the features of periodontal support physiological balance between the external and internal environment, thus preserving morphological structure periodontal disease. The purpose of examination of patients with periodontal disease is to establish the type, shape, weight, nature of the disease, and to identify common local etiologic and pathogenetic factors of the disease. The most complete information can correctly diagnose and appropriately treat the patient. In the survey used multiple methods to share on the barer and support. The main methods include:
1.sub -objective test
2. objective examination
Subjective examination consists of:
– patient complaints,
– life – history,
– history of the disease.
Physical examination consists of: – оverall review local – view general examination includes a review of all body systems. Local examination includes a review teeth-jaw system.
Local examination consists of:
– external oral;
– intra oral.
If necessary complement auxiliary examination methods (laboratory, functional, immunological and other studies), they are especially needed to provide information on the general state of health.
Subjective examination of the patient is the initial phase of the survey.
The purpose of phase – based on a patient survey to get information that will make it possible to put a preliminary diagnosis, and therefore more directed to conduct an objective examination by applying necessary to confirm the diagnosis helper methods.
During the survey is to find out the passport information of medical history, including the patient’s age and his profession, environmental and social conditions of life. This is important to determine the diagnosis.
Identify factors that preceded the disease and it can cause (acute infectious diseases, exacerbation of chronic disease, injury, surgery, stress, etc.) and improve or impair its future course.
It should also find out which survey methods used for diagnosis in which hospitals were conducted treatment and monitoring of patients. You must read the medical report excerpts from case histories, test results, X-ray, etc.
Objective examination.
Review is one of the main ways of diagnosing dental diseases, which allows you to get objective data on specific diseases. To improve information test should consistently examine the patient, taking into account the general condition and physical development, posture, facial expressions, condition of the mouth at rest and during functional loading to (chewing, breathing, swallowing, speech).
The face should examine in face and profile at rest, during conversation and for closing the teeth.
Signs describing the physiological state of dentition, the following:
· patient at rest and during sleep breathing through his nose, lips tightly closed to outside red border of lips and mucous membranes;
· during swallowing is not a reduction in facial muscles, there is no symptom of a thimble, red border of lips is not going to fold the tip of the tongue contained in the alveolar region of upper incisors;
· no snacking habit lips, tongue, injury gingival margin pencils, pens, etc.
Overview involves examination of all organs and systems (more commonly used in hospitalized patients.
Local examination begins with the patient’s external review, conducted in order to identify macroscopically visible changes maxillofacial area. Visual inspection immediately begin during the meeting with the patient. On examination, the doctor faces should pay attention to the expression (calm, tense, aggressive, depressed) proportionality in horizontal, vertical and sagittal planes of symmetry and localization of tumor or swelling; complexion, his uniform, the presence of elements of destruction, scars, fistulas.
The symmetry of the face – a correspondence between the left and right side of the face.
Increased development or backwardness of the parties – a symptom of the existing dental disease or risk factors for its occurrence. Pay attention to the severity or smoothing nasolabial folds and under the beard. These changes – a symptom of pathology bite, but it is also a risk factor for the development of other dental diseases. On examination, detect postoperative and posttraumatic scars as a child moved to surgical trauma or other etiologies – a significant cause of dental disease in the future. To this end, in addition to visual inspection of the skin, the bones of the facial skeleton palpable.
Followed to determine the condition of tone facial and masticatory muscles at rest and during functional loading, the value of oral cleft, location and nature red border of lips (color, size, presence and location of damage elements, symmetry, horizontal, closed or open, tense or atonic). The following is palpated tissues of the face, neck and lymph nodes.
Intraoral examination consists of oral examination and vestibulum oris. Review vestibulum oris mouth. This offer patients relax your lips with closed jaws and dental mirror alternately raised upper lip, lower bottom, assign cheeks, consistently and carefully examining them. During the oral examination vestibulum oris pay attention to its depth, development bridles lips, tongue, presence of bands, their place of attachment to the alveolar bone, color and texture of the mucous membrane of the mouth. Bridles lips characterized by the following clinical signs: place attachment, density and character of the ridge, the severity of the slopes, the size of diastema.
Depth of vestibulum oris is defined as the distance from the edge of the gums to the teeth 1-1 transition line on the lip mucosa at its horizontal abduction. Vestibule of mouth in the area lower front teeth on the basis of depth is conventionally divided into three types: shallow (
After visiting vestibulum oris transferred to review their own horn cavity. The development and progress of periodontal disease influences the tongue, muscle tone, presence of bad habits, the state of the frenulum of the tongue. During the examination of gums evaluate their color, surface, texture, contour and location of the land, the size and the pain, the presence of bleeding and so on. Healthy gums are pale pink color, and the interdental papillae and loose gums intensely colored due to better vascularization. Change the color of gums may occur at the group of teeth (locally) or all over their (generalized). The pathological process may be extended only to cover the nipples gums or their entire surface. Interdental papilla is genital form in a healthy child. In pathological processes gingival contour is modified.
Healthy gums
If gum disease should assess their bleeding. On the basis of history, there are three degrees of bleeding:
I- the bleeding is quite rare, mainly during use of solid food,
II- there is bleeding while brushing teeth,
III-symptoms of bleeding occur spontaneously.
Deformation of the dental arches, clusters teeth, diastema is a factor in the development of periodontal disease. Clusters of teeth directed placing them in an arc prevents oral hygiene leads to inflammation of the periodontal tissues, the appearance of traumatic occlusion.
It is necessary to note the presence and type of occlusion traumatic occlusion, which is one of the etiologic factors of periodontal disease.
Traumatic occlusion occurs when one tooth or group of teeth is closing traumatic stress.
The development of traumatic occlusion – a constant symptom of generalized periodontitis and periodontal disease. It occurs due to violation ligaments teeth and their compression. The degree of severity of traumatic occlusion is closely related to the severity of the disease and is determined by occludogram. Occludogram – a denture prints on plastic material with the usual for this individual is closing the teeth (central occlusion). You can use wax plates, strips foil, carbon paper. These prints are transferred to a dental formula using symbols: plus sign (+) – ortohnatychne value, minus sign (-) – lack of contact, 0 – beyond the occlusion, the hole in the wax pattern – overload.
The development of traumatic occlusion effect type of bite. Less likely to develop traumatic occlusion of the so-called physiological occlusion. The development of traumatic occlusion observed at concentrations of teeth, their location outside the arc, deep and prognathic bite.
An examination of children and adolescents in order to detect early forms of periodontitis and periodontal disease is required to determine the degree and nature of the manifestation of traumatic occlusion. For this purpose, using conventional method using carbon paper.Value dentition and occlusal plane convenient to define a special registration with loose carbon paper folded in half inside surface coloring, graph paper with tracing paper, placed between the two halves of carbon paper.The presence of traumatic occlusion judged by functional overloading of individual teeth in the anterior or lateral closing. First of all it is necessary to teach the patient to properly close the teeth. Mouth rinse several times with water. Cutting and chewing surfaces of teeth -antagonists dry cotton balls. The patient was asked to open his mouth. Impose registration deposit for cutting and chewing surface of one of the sites of the dentition of the upper jaw, fixing his junk on the teeth of the mandible. The patient should not open his mouth wide as tension cheeks, lips hinders proper overlay registration liner. In the lateral parts of the liner beyond the last tooth to
Registration putting liner on dentition, offer the patient safely close the mouth, strongly compressed jaw. After showing prints on one side of graph. In clinical observation insert stored in history and use it for control visits to patients.
Identified premature contacts tied, achieving an even interdigitation of the upper and lower jaw.
The local traumatic factors. Detection of traumatic factors – one of the central problems in the clinical assessment of periodontal Microbial dental plaque, tartar, improperly imposed seals and manufactured orthopedic constructions, cavities, located on the contact surfaces in the cervical region, the lack of contact point, pathology bite and teeth detached, traumatic node and so on. are stimuli that are constantly, causing the development of inflammation in periodontal or increase its flow. Identify all harmful traumatic factors acting locally, evaluate their role in the development of the disease and the need to address the complex treatment. It should outline the timing and sequence of their removal.
Then study the relationship dentition in the anterior- posterior, vertical and transver – common- directions. Type bite the child is determined at closed teeth. Occlusion anomalies study in the course of orthodontics.
Normal occlusion has the following characteristics:
1) Match the center line between the incisors in the upper and lower jaws;
2) the upper incisors overlap the lower one-third the height of the crown;
3) contacting the top of each tooth with the same name and stand behind lower than 8 8, and 1 1 teeth.
4) first permanent molars are large in this position: front upper teeth tubercles placed in the lower fissures.
Orthognathic occlusion
Severity of inflammation corresponds to the degree of pathological tooth mobility, as determined by tweezers O.I.Yevdokymovu:
The degree of mobility of the teeth is determined by palpation with tweezers or special vehicles.There are three degrees of mobility of teeth:
1st – tooth leans in vestibular- oral (labial – lingual) direction within the width of the cutting edge (1-
2 – in addition to signs of grade 1, there is mobility in media -distal direction;
3rd – in addition to these movements, tooth movement in the vertical direction.
An important clinical sign of periodontal disease is a periodontal pocket. Its appearance is due, primarily, a violation of the tooth- gingival and periodontal tissues connection. To equalize the depth of its use parodontmetr (calibrated probe).
Periodontal pocket depth – the distance from the neck of the tooth (enamel- cement border) to the bottom of the pocket is defined around each tooth individually. This is important not only for diagnosis but also for the choice of treatment (conservative or surgical), the definition of effective treatment.
The position of the bottom edge of the pocket relative to the level of alveolar bone distinguish gingival (with hypertrophic gingivitis) and periodontal (bone) pocket.
Measuring the depth of periodontal pockets.
Periodontal pocket depth estimate based on age and dentition. M F Danilevsky et al (1993) isolated outside bone periodontal pockets (alveoli without destruction of bone) and bone (with significant bone destruction alveoli). The presence of periodontal pockets, the depth and length determine the nature of the periodontal diseases. The depth of periodontal pockets measured using calibrated Smoothers or blunt probe coated with these millimeter divisions or special tool – parodontmetr.
This tool is introduced in pathological pocket until it stops feeling insignificant Depending on the group of teeth perform several measurements: a large rectangular area of the teeth – two on the buccal and lingual surfaces palate, and one on the distal and medial, in the region of small rectangular teeth, incisors and canines spend four measurements, one on each surface.
In addition to measuring the depth of the distance from the bottom edge of the gum pockets take into consideration the exposure of the root surface by gingival retraction (distance from the enamel- cement border to the top of gingival papilla).
In some diseases periodontal tissues periodontal pocket depth measurement by itself does not indicate the degree of degradation. First, repeated measurements should be made clear in the same area with exactly dosed load on the probe, but it is not always possible. Secondly, the rate of periodontal pocket depths affect the degree of edema. Therefore, the most informative is the loss of clinical attachment: distance from the enamel – cement border to the deepest point of periodontal pockets. Clinical attachment loss is the sum of indicators of periodontal pocket depth and magnitude of the recession. When hypertrophy gingival margin ratios were determined by following way: the value of the periodontal pocket subtracted indicator of gum hypertrophy, which measured from the gingival margin to the enamel- cement border.
When the diagnosis is determined not only periodontal pocket depth and clinical attachment loss, but also to evaluate bone pockets that should be carried out to plan the volume of surgical procedures using osteoplastic materials. To assess bone pockets use classification Goodman and Cohen (1980):
1 – type bone defect with 3 walls;
2 – type bone defect with 2 walls;
3 – type bone defect with one wall;
4 – combined – type bone resorption defect or crater:
a) trohstinna bone pocket;
b) double-walled bone pocket;
c) single- bone pocket.
Indexed assessment of periodontal disease.
Index Fedorov – Volodkina has been received
Index A. Fedorov and V.Volodkina received (1971) determined by painting lipstick surface of the lower six front teeth solutions containing iodine (Shyllyera-Pisarev et al.).
Quantitative evaluation exercise for competence:
5 points – shading the entire surface of the crown;
4 points – shading 3/4 of the surface;
2 points – shading 1/4 of the surface;
1 point – no one shading.
The index is determined by the formula:
HI=Y/6,
where Y – the sum of the index.
Hygienic index estimated as follows:
1,1-1,5 points – good;
1,6-2,0 points – satisfactory;
2,1-2,5 points – unsatisfactory;
2,6-3,4 points – poor;
3,5-5,0 points – very bad.
Index Green-Vermillion (1964)
The simplified oral hygiene index
To determine the simplified oral hygiene index paint vestibular surface16, 11, 26, 31, and tongue surfaces 36 and 46 teeth solution Schiller-Pisarev or other iodine solution. In the studied surfaces first determine plaque – Debris-index (DI), and tartar – Calculus-index (SI).
Evaluation Criteria Green-Vermillion index
|
Mark |
Plaque (DI) |
Plaque (SI) |
|
0 |
absent |
not found |
|
1 |
cover 1/3 of the crown |
cover 1/3 of the crown |
|
2 |
cover 2/3 of the crown |
Stone cover 2/3 of the crown, as some conglomerates |
|
3 |
covers more than 2/3 of the tooth |
Stone cover 2/3 of the crown and (or) covers the cervical portion of the tooth |
The formula:
OHI-S = ∑ P/n + ∑ T/n
where Σ – the sum of the values, P-plaque; T-tartar;- number of examined teeth (6).
Evaluation criteria for hygiene index Green – Vermilyona
|
Index group |
Index level |
Hygiene level |
|
0—0,6 |
low |
good |
|
0,7—1,6 |
medium |
medium |
|
1.7—2.5 |
high |
bad |
|
2,6 |
very high |
very bed |
Index of Silness-Loe
It takes into account the thickness of dental plaque in the cervical area. In determining the index shading plaque did not commit. Its thickness is determined by the probe on the four surfaces of the tooth: the vestibular, lingual and both contact.
Examined 6 teeth: 14, 11, 26, 34, 31, 46.
Evaluation criteria:
O – plaque at the neck of the tooth probe is not defined;
1 – raid not visually noticeable, but the tip of the probe, if they stay at the neck of the tooth visible lump bloom.
2 – Raid determined visually;
3 – intensive postponement of plaque on the tooth surface and tooth spacing.
Method of calculation:
a) for one tooth – add the index obtained by examining various surfaces of one tooth, and divide by 4;
b) group of teeth – code for individual teeth (incisors, large and small rectangular teeth) can be grouped to obtain hygiene index for different groups of teeth;
c) for an individual – add the index to the teeth and divided by the number of teeth examined.
Hygienic Index Ramfjorda
Used to determine dental plaque on the buccal, lingual and contact surfaces of six teeth 14, 11, 26, 34, 31, 46. For use colouration
The evaluation is carried out as follows:
0 – no dental plaque;
1 – dental plaque in some but not all buccal, language and contact surfaces;
2 – dental plaque on all proximal, buccal surfaces and language, but covers less than ½ the tooth surface;
3 – dental plaque on all proximal, buccal surfaces and language and covering more than ½ the tooth surface.
The index is determined by dividing the total points by the number of teeth examined.
Index of plaque on the Quigley and Hein
Index of plaque by Quigley and Nein used to estimate the amount of plaque in the coronal tooth surfaces, pre- painting the vestibular surface of the teeth. Then determine the area of painted surfaces. To apply shading flying food (erytrozyn, methylene blue) or fluorescent dyes, which for a short time deposited in the raid. Erytrozyn paints plaque that formed in red. In more mature plaque effectively influence methylene blue, giving it a blue color.
Plaque on the proximal surfaces of the index does not reflect the full.
In the index of Quigley and Hein distinguish six values:
· 0 degree: the absence of plaque;
· 1 degree: of individual plaque areas.
· 2 degree: a clear line of plaque on gingival margin;
· 3 degree: the presence of plaque in the cervical area of the tooth;
· 4 degree: the presence of plaque to limit the middle third of the tooth;
· 5 degree of presence of plaque to the coronal tooth.
Simplified plaque index on aproksymalnyh surfaces (API) by Lange.
After staining plaque appreciate its presence (in the form of answers “yes/no”) on the proximal surfaces. Removal of plaque in these areas require particularly careful of patient safety measures. Therefore, assessing the plaque stays on the proximal surfaces can determine the level of implementation of patient safety measures and hence the degree of collaboration with a physician that heals. Assessment of plaque in the proximal parts of the API index to spend on oral surfaces of the first and third squares and vestibular surfaces of the second and fourth square.
Formula for calculation:
The amount of positive results determine plaque:
ARI = x 100
The amount determined on the proximal parts
The index API estimated as follows:
API <25% – optimal oral health;
API = 25-39% – a sufficient level of oral hygiene;
ARI = 40-69% – satisfactory hygienic condition of the oral cavity;
ARI = 70-100% – poor oral hygiene status.
API values less than 35% indicates an active part in the patient’s medical activities.
Effectiveness Index oral hygiene (PHP) (Podsliadley, Haley, 1908)
To quantify plaque painted 6 teeth:
16, 26, 11, 31 vestibular surface 36. 46 tongue surface.
If there is no index teeth examined a nearby, within the eponymous group of teeth. Artificial crowns and fixed prostheses inspect parts as well as their own.
The surface of each tooth is divided into 5 sections:
1 – medial
2 – distal
3 – mid-occlusal
4 – central
5 – mid-cervical
Codes and criteria for evaluation of plaque
0 – no staining
1 – staining revealed.
Calculation of the index
Determine the code of each tooth by means of a code for each site.
Example of code for a single tooth
The figure shows examples for the calculation codes plaque on individual teeth.
A – staining detected at one site – distal.
Code plaque equal to 1
B – staining revealed three areas, medial, and distal in the mid- cervical.
Code plaque equal 1 + 1 + 1 = 3
C – painting discovered on 4 areas – the medial, distal, mid- cervical and central.
Code plaque equal 1 + 1 + 1 + 1-4
The formula used:
NRC = amount of codes all teeth÷number of teeth examined
Interpretation of the index:
The index level of hygiene:
· 0 excellent 0,1-0,6 good
· 0,7-1,6 satisfactory
· more than 1.7 unsatisfactory.
Index Tureski
S.Tureski et al. (1970) proposed a hygienic index is based on a system of counting Quigley-Hein, but the plaque thus turns on the vestibular surfaces of all language and dentition.
Evaluation criteria:
· No plaque;
· some stains plaque found on the tooth surface gum;
· a thin continuous strip of plaque (up to
· a strip of plaque wider than
· plaque covering more than 1/ 3 but less than 2 /3 of the crown.
Periodontal indices
Sample Shyllyera – Pisarev
Chronic inflammation of the periodontal sometimes symptoms (redness, swelling) are hidden. In such cases, the test conducted Schiller – Pisarev. This is clear in the area of the lower front teeth with a small watt balls smeared solution containing iodine. In the presence of hidden inflammation in the gums significantly increases the number of glycogen solution and therefore gives them a yellow- brown color of varying intensity. A light yellow color test is negative, while dark brown – positive.
Index PMA (papillary – marginal – alveolar)
Index PMA (papillary – marginal – alveolar) proposed Masser and modified Parmain 1960. Used to assess inflammation of gums.
Scale of evaluation index PMA:
1 point – inflammation of the gingival papillae (P);
2 points – inflammation of the gum edge (M);
3 points – inflammation of the gums alveolar (A).
PMA index is calculated as a percentage using the formula:
PMA index = (sum of scores / number of teeth) * 100
Total score is calculated by adding all of the highest rates of each tooth. Number of teeth aged 6 years -20, 6-11 years-24, 12-14 years – 28. 15 years and older – thirty.
Evaluation criteria:
to 20% – mild severity of gingivitis;
25-50% – average severity of gingivitis;
above 51% – a hard severity of gingivitis.
Periodontal index (PI)
Periodontal index (PI) proposed by Russel in 1956 and is used to identify inflammatory and destructive changes in the periodontium. In its definition is evaluated periodontal condition around each tooth. In this case, taking into account the degree of inflammation, glycine gingival pockets, mobility of the teeth.
Evaluation criteria:
O – no inflammation;
1 – mild inflammation which does not cover all the gums around the tooth;
2 – inflammation covering the entire surface of the gums around the tooth, but not epithelial attachment broken (no periodontal pockets);
4 – in the above data observed X-ray bone resorption;
6 – gum disease, the presence of periodontal pockets, tooth fixed;
8 – rolling tooth is periodontal pockets (pronounced destruction of all periodontal tissues).
The formula:
RI = total score of all examined teeth÷number of teeth examined
Interpretation:
0.1 -1.0 – initial stage of periodontitis;
1.5 – 4.0 – medium severity;
4.5 – 8.0 – severe stage of periodontitis.
Index (CPITN) (1989)
To determine the need for treatment of periodontal diseases apply color code
CPITN. To assess this index using three factors:
1. The presence or absence of bleeding gums;
2. Having over – or under the gum stone;
3. Periodontal pockets – shallow (4-
To indicate the parts of the mouth using the codes adopted by the International Organization for Standards:
01 – upper jaw;
02 – lower jaw.
03-08 – Sextant in the mouth as follows:
sextant 03 – upper right premolars and molars;
sextant 04 – upper canines and incisors;
sextant 05 – upper left premolars and molars;
sextant 06 – lower left premolars and molars;
sextant 07 – lower canines and incisors;
sextant 08 – lower right premolars and molars.
Double figures indicate some teeth in accordance with the system adopted by the International Dental Federation (IDF). The first number indicates the quadrant of the mouth, the second – the tooth.
Temporary 55 54 53 52 51 61 62 63 64 65 Maxilla
Standing 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 maxilla
Standing 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 mandible
Temporary 85 84 83 82 81 71 72 73 74 75 mandible
Marking the tooth is recommended to give the number of square and then the number of the tooth. To investigate the oral cavity is divided into six sextants to determine the teeth of the code number 18-14, 13-23, 24-28, 38-34, 33-43, 44-48. Sextant inspected only if there are two or more teeth and there is no indication for their removal. If sextant survived only one tooth, it should include in the previous sextant. To determine the index teeth in persons under 19 years examined, only 6 teeth: 16, 11, 26 and 36, 31, 46. During the inspection of children under 15 registered pockets do not perform, that take into account only the presence of bleeding gums and stone. If sextant that it should look, there is no index tooth replacement can serve individual incisors or premolars, which are fully erupted. Probing perform at the first molars and incisors (in people under 19 years).
CPITN index estimated by the following codes:
· 0 – no signs of inflammation;
· 1 – gingival bleeding after probing;
· 2 – the presence of over-and bellow gums tartar;
· 3 – pathological pocket depth 4…
· 4 – pathological pocket depth of
The formula:
RI = total score of all examined teeth÷number of teeth examined
Interpretation:
0 – treatment not needed;
1 – should improve hygiene;
2 – requires a course of occupational health;
3 – shows a local anti-inflammatory therapy
4 – shows the combined treatment.
Comprehensive periodontal index (CPI)
Designed in
Evaluation criteria:
0 – abnormalities not detected;
1 – plaque;
2 – bleeding;
3 – tartar;
4 – periodontal pocket;
5 – tooth mobility.
Depending on the age of the teeth are examined:
3-4 years 55, 51, 65, 75, 85
at 7 – 14 years 16, 11, 26, 36, 46
more 15 years – 17 (16) 11 26 (27) 47 (46) 31 36 (37)
Define KPI individual and KPI medium:
KPI
KPI m =amount of individual KPI ÷ number of teeth examined evaluation
Criteria:
0.1-1.0 – risk;
1,1-2,0 – mild disease;
2,1-3,5 – average degree of disease;
3,6-6,0 – severe degree of the disease.
Index of gingivitis (IG)
The proposed in 1967 Silness -Loe, characterizes the severity of inflammation in the gums.
We investigate the gums on all sides, measured on a 4- point scale:
· No inflammation;
· Mild inflammation (slight discoloration, no bleeding when touched);
· Moderate inflammation (redness, swelling, possible bleeding when touched);
· Severe inflammation (severe redness, swelling, ulceration. Unauthorized bleeding).
The sum is divided by 4 and find the index of the tooth. This index should be determined by the molars, premolars and incisors on each jaw.
Evaluation criteria:
0.1 -1.0 – easy gingivitis;
1,1-2,0 – moderate gingivitis;
2,1-3,0 – severe gingivitis.
Index Ramfiord
The proposed S. Ramfiord (1956). Evaluate two metrics: gingivitis varying degrees of depth and pathological tooth- gingival pockets.
We study in periodontal 16, 21, 24, 36, 41, 44 teeth. Inspect the condition of the gums and periodontal pocket depths from all examined teeth.
Evaluation criteria:
· Mild inflammation of the gums from any one side of the tooth;
· Moderate gingivitis (redness, swelling);
·
· Periodontal pockets up to
· Periodontal pocket depth 3…
· Periodontal pockets deeper than
The index should be used in children and adolescents after complete dentition.
Sulcus bleeding index (SBI) for Muhlemann and Son
The degree of sulcus bleeding index is determined through 30 after careful parodontal sensing probe.
This index shows the six degrees of inflammation:
· 0 degree: appearance of gums is not changed at sounding no bleeding;
· 1 degree: the appearance of gums is not changed at sounding bleeding occurs;
· 2 degree: the appearance of discoloration due to gum inflammation, bleeding occurs in probing;
· 3 degree: same as 2 degrees, but this appears mild swelling of the gums;
· 4 degrees 3 similar extent possible occurrence of pronounced inflammatory edema;
· 5 degree similar to 4 degrees may cause spontaneous bleeding and gingival epithelial erosions.
Simplified gingival sulcus bleeding index
This index determines the presence or absence of gingival bleeding in probing the sulcus by answering yes/no for this reason can only be a rough estimate outcomes. In practice, this index is usually used together with an index API. On this index assess vestibular surfaces of the first and third quadrants and language surface second and fourth quadrants.
Papillary bleeding index (PBI) to Saxer and Miihiemann
After this occurrence indices, bleeding nipples after careful probing of gingival sulcus. Using PBI, can be a simple and accurate way to monitor the progress of inflammatory periodontal diseases. As the index API, to perform sensing lingual surfaces of the first and third quadrants and the vestibular surfaces of the second and fourth quadrants index value is determined for each quadrant and then derive the average value for the entire bite.
Bleeding on probing:
A) Assessment of bleeding in probing the marginal Gums
B) Bleeding after probing the bottom of grooves or pockets.
In the index PBI adopted the following evaluation of bleeding:
· 0 degree, no bleeding;
· 1 degree the appearance of some point of bleeding;
· 2 degree by numerous bleeding point or linear bleeding;
· 3 degree filled with blood under the gums interdental triangle;
· 4 degree after sensing appears intense bleeding.
The data about the depth of periodontal pockets and tooth mobility made in odontogram-that is to assess the periodontal tissues.
The data obtained by probing, consistent with the results of X-ray examination. Odontogram is of particular importance in repeated surveys, allowing judged by comparing the dynamics of the process and the outcome.
SOURCES OF INFORMATION
1. NF Danilevsky, A. Borisenko Periodontal Disease, Kyiv “Health”, 2000, 49-80 p.
2. Danilevsky NF, Borisenko AV Periodontal Disease. – K. Health, 2000. – 463 p.
3. Ivanov V. Periodontal Disease. – M., 2001. – 304 p.
4. Kuryakyna IV, Kutepova TF Periodontal Disease. – N. Novhorod, 2000. – 161 p.
5. Modern Aspects of Clinical Periodontology/Ed. prof. L. A. Dmytryev. – M, 2001. – 128 p.
