Prosthetic Rehabilitation of a Patient with Nose Defect

Prosthetic Rehabilitation of a Patient with Nose Defect Case Report Authors: Satyabodh S Guttal, MDS,MFPT 1, Blessy Bangera, BDS,2 Adarsh Kudva,  MDS,3 Basavaraj R Patil, MS, 4 Abstract Midfacial defects are enormous defects that result from cancer treatment that rarely are corrected by surgical reconstruction alone; they generally require a facial prosthesis to restore function and appearance. Surgical reconstruction may be viable for few defects, which are done with different flaps. But for the total nasal resection, prosthetic option would be more feasible. Nasal cartilaginous anatomy is complex due to the varying contours. Therefore it may be difficult for the surgeon to reconstruct the entire nose. This clinical report describes the rehabilitation of a large midfacial nose defect with a dental implant retained nasal prosthesis. The patient had adenocystic carcinoma of the medial maxillary wall extending to the nose. Introduction The face being the most noticeable part of the body when disfigured may lead to an impaired social life stemming from esthetic problems. 1, 2 Among facial defects, nasal defects produce severe cosmetic impairment. . Rehabilitation of such defects subsequent to surgery is done in a sequential manner, which includes a surgical, provisional, and definitive prosthesis. 3 Prosthesis helps restore the patients self-esteem and confidence, hence affecting the patients and their life style. 4-6 Adenoid cystic carcinoma (ACC) is a rare malignant perineural tumour of the major and minor salivary glands, accounting for 2% of all head and neck malignancies and approximately 10% of all salivary gland neoplasms. 60% to 70% of ACC’s arise in the minor salivary glands, which may be localized in the palate, paranasal sinuses and nose, although they may also occur in the parotid or submandibular glands.7 In the past, nasal prostheses were held in position with strings or straps fastened behind the head,8 intranasal or intraoral extensions,9,10 and gold strings or leaves.11-13 Spectacle frames have been accepted for securing nasal prostheses.14,15 Today, with the development of biomaterials, prosthetic substitutes are secured with readily available adhesives that are effortlessly applied 16 however, the effectiveness of adhesives is questionable considering presence of mobile tissues in the defect, nasal secretions, and moist air associated with respiration.17 These factors would compromise the adhesiveness. The concept of osseointegration 18 has enabled a more reliable mode of retaining nasal prostheses. 19 This clinical report describes the rehabilitation of a large midfacial defect using an implant retained nasal prosthesis. Clinical Report: A 63-year-old female patient who reported to the B.R Patil Cancer hospital, Navanagar, Dharwad was diagnosed with adenocystic carcinoma of the medial maxillary wall. Patient had no medical co-morbidity. Patient gave history of nasal obstruction due to nasal mass on left side of the nostril for which medial maxillectomy was done via endoscopic approach in the year 1993. Then in 2012 she reported back with the complaint of nodular swelling over nasal dorsum with tearing and nasal obstruction with no orbital symptoms. Intra-orally patient had destruction of palate on the left side crossing midline. Upon further investigation, biopsy revealed adenocystic carcinoma of the nose and left maxilla with no involvement of orbit or anterior skull base (Fig 1). Two cycles of chemotherapy with cisplatin, 5 flurouracil and paclitaxel according to body surface area was given. The defect resulting after excision had to be covered at the earliest. Hence, prior to surgical intervention, prosthetic consultation was suggested to the patient who was thus referred to our Department of Maxillofacial Prosthodontics. Since an immediate definitive prosthesis was not feasible, the patient was suggested for temporary rehabilitation with an interim silicone nasal prosthesis with an attached eyeglass frame. However, since the patient expressed her displeasure towards spectacles for lifelong usage, she was given the option of implant-retained definitive silicone nose prosthesis. The patient agreed for the same. An orthopantomograph and computerized tomography scan were made as a part of the investigation to evaluate the bone height for implant placement. Left total maxillectomy with palatal resection across midline and total nasal resection done via weber ferguson incision, left modified radical neck dissection type three via macfee incision was made. The glabellar bone was evaluated on the operation table and upon conclusion that adequate bone was available; a single implant of 4.2 diameter x 6.5mm length, (Toureg S; Adin implants, Nazareth, Israel) was placed (Fig 2). The advantage of placing the implant on the operation table was that the patient would be under general anesthesia, and the psychological trauma of undergoing another surgical procedure was avoided. Following a healing period of 3 months the open tray impression posts were placed and the final impression was made. The abutment was placed on the implant and a custom made acrylic sleeve was fabricated for the abutment (Fig 3). A wax sculpted nose on the master cast was made to adapt to the margins of the healing wound. On either sides of the acrylic resin sleeve, two neodymium-iron-boron magnets, 5mm diameter x 1.2mm thick (Magnatech; Mumbai, India) were embedded into extensions made out of autopolymerising resin. The structure hence resembled a winged sleeve which was cemented on to the abutment using zinc-phosphate cement (Harvard Dental, Hoppegarten,Germany) (Fig 4). An acrylic resin index was fabricated over this structure which would harbor the respective magnetic keepers. The acrylic index was placed at its position over the magnets and was picked up by the wax nose that was placed on it using a drop of cyanoacrylate. The resulting wax nose thus incorporated an acrylic index with the magnetic keepers. This wax nose was carefully invested and the packing procedure using silicone and acrylic resin border framework, intrinsic coloring was carried out as mentioned for the interim above. Extrinsic coloring and pigmentation was done and patient was happy with the esthetic results. Digital weighing scale revealed that the definitive nasal prosthesis weighed around 12.2gms. The retentive force offered by the two neodymium-iron-boron magnets (Magnatech; Mumbai, India) was found to be 7.2N. The prosthesis was delivered to the patient (Fig 56). Following this, home-care instructions were given. In the subjective evaluation, the patient was very happy with the esthetics outcome of the prosthesis and expressed her great pleasure towards her ability to swallow liquids. The ryles tube continued to remain in place considering the general health condition of the patient and the need to feed semi solid food and protein supplements. The prosthesis was light in weight and could be comfortably placed in position as it was self-aligning due to the use of magnets. Patient, who is now on regular periodic follow-up ie, recalling at every 3 month period, is found to be doing well. Discussion Nasal reconstruction modalities comprises of primary closure, healing by secondary intention, skin grafts and local flaps and regional flaps. Small surgical defects can be treated well with different types of local flaps. The forehead flap is the better option for the large nasal defects. 20 The complex anatomical configuration may cause difficulty in surgical rehabilitation. In such cases, prosthetic closure is predictable and hence usually the treatment of choice. 21,22 The breakthrough for rehabilitation of facial defects with implant-retained prostheses came with the development of the modern silicones and bone anchorage. The limitations of the prosthesis were explained to the patient prior to the treatment, that fact that the prosthesis would enhance esthetics but would contribute less to the functions like speech and masticatory habits. Hence, the patient had no psychological set back on the prognosis of the treatment. In addition, there was a major set-back in terms of achieving outstanding esthetical and functional outcome due to the fact that all the work was carried out under technical constraints. This included a lack of time, chair-side patient availability, and ideal light conditions which, to an extent precluded optimal color blending. The main objective of treating this case was to close the open defect, to prevent the further spread of infection in the soft tissues exposed to the environment. The use of a magnetic assembly has eliminated the need for use of spectacle retention as per the patient’s request. The patient indicated that the nasal prosthesis reduced self-consciousness and was comfortable to wear without any type of irritation to the surrounding skin. The patient was pleased with her appearance and no longer found the need to wrap a cloth around her face. References Guttal SS, Patil NP, Thakur S, Kumar MV, Kulkarni S. Implant-Retained Nasal Prosthesis for a Patient Following Partial Rhinectomy: A Clinical Report . J Prosthodont 2009; 18:353–8. Kumar S, Rajtilak G, Rajasekar V, Kumar M. Nasal prosthesis for a patient with xeroderma pigmentosum. J Pharm Bioallied Sci 2013; 5:176-8. Marunick MT, Harrison R, Beumer J. Prosthodontic rehabilitation of midfacial defects. J Prosthet Dent 1985; 54:553-60. Buzayan MM. Prosthetic management of mid-facial defect with magnet-retained silicone prosthesis. Prosthet Orthot Int 2014; 38:62-7. Jain S, Maru K, Shukla J, Vyas A, Pillai R, Jain P. Nasal prosthesis rehabilitation: a case report. J Indian Prosthodont Soc 2011; 11:265-9. Anantharaju A, Kamath G, Mody P, Nooji D. Prosthetic rehabilitation of Oro-nasal defect. J Indian Prosthodont Soc 2011; 11:242-5. Shimamoto H, Chindasombatjaroen J, Kakimoto N, Kishino M, Murakami S, Furukawa S. Perineural spread of adenoid cystic carcinoma in the oral and maxillofacial regions: evaluation with contrast-enhanced CT and MRI. Dentomaxillofac Radiol 2012; 41:143–51. Saunders RCH. The gunner with the silver mask. Am Med Hist 1941; 3:283-5. Kazanjian VH, Rowe AT, Young HA. Prosthesis of the mouth and face. J Dent Res 1932;12:1 Kazanjian VH. Treatment of nasal deformities. J Am Med Assoc 1925; 84:177. Bulbulian AH. Facial Prosthetics. Springfield IL, US, Ed 1, 1973 pp. 364-7. Baird WH. An artificial nose. Dent Cosmos 1905; 47:560. Baker L. An artificial nose and palate. Dent Cosmos 1905; 47: 561. Rodrigues S, Shenoy VK, Shenoy K. Prosthetic rehabilitation of a patient after partial rhinectomy: a clinical report. J Prosthet Dent 2005; 93:125-8. Guttal SS, Patil NP, Shetye AD. Prosthetic rehabilitation of a midfacial defect resulting from lethal midline granuloma: a clinical report. J Oral Rehabil 2006; 33:863-7. Parel SM. Diminishing dependence on adhesive for retention of facial prosthesis. J Prosthet Dent 1980;43:552-60. Parel SM, Branemark PI, Tjellstrom A, Gion G. Osseointegration in maxillofacial prosthetics. Part II: extraoral applications. J Prosthet Dent 1986;55:600-6. Brà ¥nemark PI, Adell R, Breine U, Hansson BO, Lindstrà ¶m J, Ohlsson A. Intra-osseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg 1969;3:81-100. Nishimura RD, Roumanas E, Moy PK, Sugai T. Nasal defects and osseointegrated implants: UCLA experience. J Prosthet Dent 1996;76:597-02. Kose R, Okur MI. Reconstruction of the defects in the middle of the nose with subcutaneous pedicled nasolabial island flap: report of two cases. Kulak Burun Bogaz Ihtis Derg. 2009;19(5):272-276 Sashi Purna CR, Annapurna PD, Ahmed SB, Vurla S, Nalla S, Abhishek SM. Two-piece nasal septum prosthesis for a large nasal septum perforation: a clinical report. J Prosthodont 2013;22:143-7. Goveas R, Puttipisitchet O, Shrestha B, Thaworanunta S, Srithavaj ML. Silicone nasal prosthesis retained by an intranasal stent: a clinical report. J Prosthet Dent 2012;108:129-32. Figure Legends: Fig 1: Preoperative patients photograph Fig 2: Placement of titanium dental implant in the glabella,-confirmed on the x-ray. Fig 3: Abutment threaded to implant and the trial of acrylic resin sleeve done. Fig 4: Cemented acrylic resin framework embedded with magnets on either side. Fig 5: Comparison between before and after prosthesis placement. Fig 6: Lateral profile of before and after prosthesis placement. Spectacle glasses were given to camouflage the borders of the prosthesis.

Elements Of A Shakespeariean Tragedy :: essays research papers

Elements of A Shakespeariean Tragedy   Ã‚  Ã‚  Ã‚  Ã‚  Shakespeare wrote many tragedies, which included The Tragedy of Julius Caesar. He chose to take an important event in Roman history, the death of Julius Caesar to write a play for the Globe Theater in 1599. The people who lived during the Renaissance were very interested in the play and the story of Julius Caesar's death. People's views of the play dating from 1599 to the present may be very different and continually changing. Though the elements of Shakespeare's tragedy Julius Caesar and other Shakespearian tragedies are all the same. A Shakespearian tragedy is comprised of several elements; two include a tragic hero and supernatural elements.   Ã‚  Ã‚  Ã‚  Ã‚  In a tragedy, the tragic hero is of high social position. The tragic hero has a destructive flaw which in turn brings about his downfall. There is much argument over who the tragic hero is in The Tragedy of Julius Caesar. Some scholars say that the tragic hero is Julius Caesar, while others say it is Marcus Brutus. A case can be made for both of the characters. Both Brutus and Caesar are of high social and political status. Caesar was the dictator for life of Rome and Brutus was an honorable Senator. Julius Caesar had two tragic flaws. Caesar was said by Brutus to be ambitious, which led directly to his downfall - â€Å" But as he was ambitious, I slew him.† (Act 3. Scene 2. Line 28) Caesar was also arrogant, he believed that he was too great to be harmed, Caesar said â€Å" Cowards die many times before their deaths; the valiant never taste death but once.† (Act 2. Scene 2. Lines 34-35) Brutus too, had a tragic flaw. Brutus was an idealist, not a realist. Brutus was an optimist, he always wanted the best for Rome. Although sometimes, Brutus couldn't see things for what they really are. This flaw prevented him from making good decisions.   Ã‚  Ã‚  Ã‚  Ã‚  The supernatural elements present in the play all foreshadow events to come. Three different characters show supernatural predictions. The Soothsayer has an insight of trouble for Julius Caesar and he warns him - â€Å"Beware the Ides of March.† (Act 1. Scene 2. Line 21) On March 15, the date that Caesar was warned of, his wife, Calphurnia had bad dreams. Calphurnia cried out in her sleep â€Å"Help ho, they murder Caesar!† (Act 2. Scene 2. Line 3.) Calphurnia knew that her dreams were a sign of what was to come. After Caesar's death, another supernatural event occurred. Marc Antony and Octavius were at war with Brutus and Cassius. Brutus was in his tent where his army was camped when the ghost of

Religious and Ethnic Groups Paper Essay

There is a lot of diversity when it comes to religion and race, mostly because of the lack of understanding each of them. If we take the time to learn a little bit about them I think that it will open our eyes and let us be more accepting of whom they are. Although there is a lot of discrimination in the world today we are still a lot more understanding than our ancestors where. The religious group that I have chosen is Jehovah’s Witnesses because they are more shunned against than any other religion I know. As for the ethnic group I chose is Black (African descent) because it seems to me that they are more discriminated against than any other race. Jehovah’s Witnesses beliefs are somewhat similar to the Christian beliefs, for example, they rely on the authority of the Bible, worship only one God and trust in Jesus’ death and resurrection for salvation. Some of the differences from the other religions are that they reject the doctrine of the Trinity and the existence of Hell, believes that Gods name is Jehovah, and they also believe the Holy Spirit to be Gods active force. They also believe that only 144,000 people will go to Heaven to rule with God and those that are left on earth that are deemed worthy will live in a restored Garden of Eden. Witnesses also believe that the purpose of Jesus incarnation of earth was threefold, which are as follows, To teach the truth about God, To provide a model of perfect life for people to follow, and To sacrifice his life to set humans free from sin and death. It is their belief that Jesus was not nailed to a cross but rather a single upright stake and that God raised Jesus fro m the dead, as a spirit creature, and he returned to Heaven, but that he was not made King until 1914. Witnesses try to push their religion onto other people without even taking that they already have a religion into consideration. They go door-to-door and try to get others to believe the way they do and also try to convert people with other religion. This causes people to become very upset and sometimes they  become very aggressive and violent towards the Witnesses. There tends to be a lot of very heated discussions on whether their beliefs are what is right and others beliefs are wrong no matter if they worship the same God or not. There are several ways that Witnesses have contributed to the American culture over the years, for example, they have administered functions called â€Å"The Society† and the â€Å"Watch Tower Society†, which they have used to put out their version of the word of God. They have won several court cases in which it has let people have their own religious freedoms to worship as they please. Witnesses have also made it to where you can have an operation and not have to accept a blood transfusion since because of their religion they do not believe in getting. There are several different procedures now that can be done without a transfusion when one was needed the way they done the surgery before. In their religion they are extremely discriminated against because of how they worship and what they believe. The sources of this prejudice is from the people but also mainly from the government because of their concern that it is wrong for them to spread the word the way they do, so to speak. For example, the French government branded them a â€Å"Dangerous Sect.†, and 71 Kingdom Halls where vandalized, burned and shot at and also fire bombed because of how they worshipped. French officials also publically called them criminals and taxed 60 percent on their religion and conveniently forgetting to tax other religions. Also Moscow even went as far as to outlaw their religion and said that they cannot even have a house of worship nor could they practice their faith in the privacy of their own home. There are several other ways that this religion has been discriminated against because of what they believe and how they choose to worship even though when it comes right down to it in the end we all really believe in the same outcome. I have learned a lot about this religion from the research that I have done and I do believe it has helped me understand them more because in the beginning I had no clue exactly what they believed in or how they even practiced their faith. Although I don’t agree with some of the things that they do and some of the ways that they perceive what they Bible says I am more accepting of who they are. The racial/ethnic group that I have chosen for this assignment is African decent because I think that they are more discriminated against than most  race’s that I know. They differ from other ethnic groups because for one their culture is different than most others, such as ancestry is different, culture and sometimes language can be different. This race has experienced different things with different cultures, for example, sometimes people that are Caucasian tend to treat them like they aren’t good enough for them to even talk to and that can cause a lot of controversy between the two ethnic groups. I think that in this day and age that everyone is more accepting of what color, gender, race or anything that is considered different than they were before. This race has contributed so much to the American culture and has made everyone look at some things in a better light so that they have a better understanding of what they went through in their history. They have paved the way for different races in a way that will help for hundreds of years to come. For example, they have made a huge impact with our music, religion, cuisine, clothing and hair styles, and several more. I believe that if they didn’t bring all these things to the American culture than it would be an extremely boring place to live. They seem to make things come alive, for example, they are more active when a church service is going on, they sing, dance and generally have a great time listening to the teachings of the Lord, which in itself is something that one needs to experience. There is also quite a bit of discrimination towards them to the point where it leads to a lot of violence. A woman named Rosa Parks was arrested on December 1st, 1955 because she refused to give up her seat on the bus because the white section was already full. Another example was slavery where white Americans bought, sold and traded African Americans so that they could use them to do the work that they didn’t want to do. They were treated as if they weren’t even humans at all, they were beaten, hanged, starved and degraded so bad because of the color of their skin. The main sources of this discrimination are of the white decent. I have learned quite a bit about this race to the point where I do understand them a lot more than I did. I’m not the kind of person that looks at the color of someone’s skin before I get to know them and because of that I am one of many who tries to accept everyone for who they are. The two groups that I have chosen are somewhat similar when it concerns what they have gone through in history to get to where they are now because of  the narrow minded people out there. They are extremely different in just about every way there is but there are some African descent who are Jehovah’s Witnesses and they have to struggle twice as hard to be accepted for who they are. My conclusions about the discrimination between the two are that no matter what religion you are or what race you are there is always going to be problems because of the lack of acceptance and understanding from other race’s and other religions. References: http://www.religionfacts.com/jehovahs_witnesses/beliefs.htm http://jw-media.org/beliefs/index.htm http://www.watchtower.org/library/rq/index.htm?article=article_02.htm http://www.britannica.com/eb/article?eu=44484 http://www.apologeticsindex.org/j02ab.html http://www.cesnur.org/testi/geova_USAtoday.htm http://www.nbcnews.com/id/12466831/ns/health-health_care/t/bloodless-surgery-avoids-risks-transfusion/ http://www.bellaonline.com/articles/art1856.asp http://fatwestcoast.blogspot.com/2010/04/african-american-culture.html

Schizophreni A Common And Serious Disorder Essay - 1645 Words

Schizophrenia is one of the most common and serious disorder in the United States. In their 2002 publication, â€Å"Violence and schizophrenia: examining the evidence,† Elizabeth Wals h, Alec Buchanan and Thomas Fahy discuss that, â€Å"In the United States alone there are a minimum of two million schizophrenics.† Though schizophrenia is a widely known disorder that has been common in the United States since the late 1880s, its causes are not yet fully known. Schizophrenia not only affects the patient; it can also lead to serious emotional damage to the person’s family. In their 2015 publication, â€Å"Visualization analysis of author collaborations in schizophrenia research,† Ying Wu and Zhiguang Duan state that schizophrenia is, â€Å"characterized by abnormal mental functions and disturbed behaviors, which characteristically appear as a series of clinical features such as positive and negative symptoms, and disturbances in basic cognitive functions (1 ). Schizophrenia is an extremely dangerous disorder and leaving it untreated can lead to dangerous outcomes to the patient and the people around them. Schizophrenia is a very common disorder, for some people it can appear suddenly without any warnings, but for others it comes slow, with small warnings leading to a gradual decline in functioning before schizophrenia decides to take over. Signs that usually begin to show when a person is schizophrenic is, depression, withdrawal, inability to express joy, cry, oversleeping, or insomnia, or

The Police And The Media - 1350 Words

The police and the media have been very closely related to one another for a very long time and they will always have to have a relationship with them. They are so closely related because crime itself is considered news that is valuable to the people of a community. Without the media and law enforcement working together, many people would not know what was going on and/or how to act about certain crimes if there are any within their communities. With that in mind, law enforcement must keep up with all the advancing technologies that involve any kind of media. This includes social media, print, internet, television, and cell phones as well. Keeping up with all these different media platforms, working together with the media, and staying on†¦show more content†¦Loads of information was given out and assisted many people. Information like this can also help the law enforcement officers on duty considering they are receiving this and can perform tasks to spread that news and hel p the community. Not only is the media a good tool for the police, but the police help the media as well. Crime is great for ratings and attracts more viewers because the public wants to know exactly what is going on. This gives the media more things to talk about during their news segments which will help fill in the amount of time their show is and inform those of anything to look out for that is associated with the crime that has happened. When the people become active in helping the police through social media, they help the police department build a positive reputation. This will generate a more positive feel towards the police and how they are portrayed through the media. Positive vibes are essential, especially in today’s society given how big the Black Lives Matter movement is. With this, there would be more light hearted news segments about the police which could result in a safer environment for the police and the people. The media also helps the police in the sense that they can let the public know about special programs they have to offer. For example, by having the local news talk about a program that teaches children what to do when they are offered drugs, or a program that kept children busy with sports, theyShow MoreRelatedThe Media Of Police Officers1605 Words   |  7 Pagesus our portrayal of police officers has been shaped by media. The media creates shows such as Rookie Blue which shows police officers and their day to day lives. These shows are heavily fantasied. Media portrays the life of an officer as dangerous and fast. Most of the public views an officers job as chasing the bad guy and solving crimes, but in reality it is far more than that. These mythical portrayals of officers create false images of police officers. 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Main Theories Of Schooling Implied By Marx s Historic...

In the modern capitalist society, social class is the most prominent and common categorization of people based on their income, occupation and education. In Marx’s view, this type of social system requires educated citizens to become either the owner of the means of production or workers that sell the labour to function the society. To this end, school are used as a mechanism to reproduce an efficient and obedient working force and maintain the dominant position of the elites. This essay seek to analyse and criticize the central purpose of schooling implied by Marx’s historic materialism. It is important to investigate the causal factors of inequalities underlie the seemingly fair education structure, so that we can search for ways to reform to achieve human liberation ideals, prevent exacerbate the class division. Karl Marx, is a German political philosopher. Jean (2011) documented that he developed the historic materialism relates social formation to the modes of production. He divide the society into two components, the superstructure and the base structure. The superstructure, contains family, media, politics etc regulates, control and monitor the base structure which includes relation and means of production; the base structure offer life necessities and support the superstructure. School is an institution that is placed at the intermediate position integrated with these social relations. Therefore, to explore the roles of education in this form of society, we need

Environmental Pollution and Control †Free Samples to Students

Question: Discuss about the Environmental Pollution and Control. Answer: Introduction With the progress of time, urbanization and development has resulted to be the root cause for environmental depletion. Any developing country tries to construct and develop by exploiting nature and eventually unacceptable consequences are foreseen (Alam et al. 2016). While focusing on Indonesia, it can be said that the environment is much affected by air pollution and the reasons are mostly because of human activities. Air pollution has not only impacted on human health, respiratory problems and lung diseases but also depleted the ozone layer by emitting excessive amount of green-house gasses (Yoo, Kim and Hadi 2014).This research will discuss the factors and challenges that Indonesia is facing related to air pollution and will finally highlight some suitable recommendations for reducing the same in future. Indonesia is developing and therefore there are plenty of infrastructure development projects, which are mostly emitting huge amount of carbon in the atmosphere resulting in more toxic chemicals through oxidization. Most of the projects are developed though burning dense forests in favor of getting empty land. However, this has led Indonesia to be the 6th largest emitter of greenhouse gases. Indonesia contributes 4.5% of global greenhouse gas emissions (Papargyropoulouet al. 2015). Some of the major challenges are listed below: Burden imposed to government from fuel subsidy 12% Carbon dioxide emission resulting from land transportation 90% air pollution occurring due to CO, HC, NOx, SOx, PM and O3 Challenges from Free Trade ASEAN Economic Community (2015), UNECA Regulation and ASEAN MRA (2012) With the effect of urbanization there has been accelerated population and housing demands, which resulted in clearing dense biologically forests. Deforestation in Indonesia is mostly done through open fire that resulted in emitting carbon. 80% of deforestation is done illegally by logging industries, which has ranked Indonesia to be the 3rd largest greenhouse gas emitter (Brunet al. 2015). Carbon reacts with oxygen in the atmosphere to emit carbon dioxide gases in excess to oxygen creating an imbalance of fresh air. On the other hand, carbon when reaches to the stratosphere, reacts with ozone to create hydrochlorofluorocarbons, chlorofluorocarbons and halons. Therefore, such coolants are being destroyed to allow ultraviolet rays to penetrate atmosphere resulting in skin diseases and cancer (Alesina, Gennaioli and Lovo 2014). Since there is excessive deforestation in Indonesia through forest fires, carbon has been the main cause for air pollution. Industrialization and Transportation Atmosphere of Indonesia is filled with harmful sulfuric acid. These are mostly emitted from transportation vehicles. Sulfur oxides released in the atmosphere precipitates through acid rains. This includes smog, fog and rain associated with particulate matters (Sari, Sulistyo and Utomo 2017). Soil, water bodies and trees are getting eroded due to acidification. There have been more than 16,000 premature deaths in Indonesia as recorded in 2012 just because of air pollution and toxic chemicals (Braueret al. 2015). On the other hand, due to industrialization from pulp and paper industries and logging industries hasled to fuel combustion for manufacturing releasing toxic sulfur and nitric acids in the atmosphere. The government of Indonesia can be considered as failure in resolving corruption and illegal activities. Conservation of land and environment protection could have been concrete if there would have been policies, rules and regulations (Aboodet al. 2015). Indonesia is extremely poor in limiting resource exploitation and natural resource consumption. Builders, promoters and syndicates are the most responsible for deforestation and soil erosion and illegal timbre logging business. However, the futile environmental policies from government have resulted in poor resource management. Emission of carbon has resulted in ozone layer depletion resulting to allow harmful ultraviolet rays to penetrate. These rays have created human skin diseases, cancer and premature deaths. Also, there has been huge amount of carbon in excessive to oxygen creating more carbon dioxide and carbon monoxide. Both of these gases along with sulfur and nitrogen affects the environment through acid rain, smog and fog (Nakazawaet al. 2016). On the other hand, Eutrophication has resulted from excessive nitrogen emitted from transport vehicles and industries, which continues to impact water bodies by killing fishes, plants and animal diversity. Eutrophication has also destroyed the marine ecosystem by ageing lakes and estuaries. Indonesian landforms are mostly affected due to acid rains associated with smog. Smog is the combination of fog and smoke containing particulate toxic chemicals. These chemicals react with buildings and sculptures to erode the surfaces. Such erosion destroys buildings due to which more resources are consumed for restructuring and redesigning. On the other hand, due to acid rain, the most impacted are plants and trees as the leaves are eroded due to acids. Once the surfaces of tree leaves are eroded, it impacts on photosynthesis and finally death occurs (Langmann 2014). This impacts on soil erosion, loss of plantation and finally raising the toxicity in bare land, which cannot be used for agriculture in future. Atmosphere of Indonesia is completely filled with methane, sulfur, carbon monoxide, nitrogen oxide, sulfur oxide, carbon dioxide, Chlorofluorocarbons and other particulates. All these gases cumulatively have resulted to impact mortality. On the other hand, not so severe yet considerable challenges such as skin tan, Cardiovascular diseases and Lung diseases are quite prominent. Considering agriculture, toxic gases in atmosphere containing sulfur will react with fresh green vegetables to increase the amount to toxicity (Hayasakaet al. 2014). Once consumed, this will result in cancer and health deterioration in long term basis. Requirements for Overcoming Challenges The above discussion has highlighted that air pollution is mostly occurred in Indonesia due to forest fire. Therefore, deforestation has to be prevented in future completely and more plantation has to be done. The supplier commodity of agriculture must stop forest clearance immediately and any further peatland development has to be halted. Moratorium for peatland concession licensing has to be introduced (Alesina, Gennaioli and Lovo 2014). On the other hand, water management measures can be implemented through re-flooding critical areas, which will eventually reduce fire risks. Asia Pulp Paper has been found to be the only company for maximum forest burning and therefore, the government has to take measures for preventing their illegal activities. Taking initiatives such as planting trees in road sides, parks and house gardens will surely reduce air pollution and releasing more fresh air in the atmosphere. The transportation of Indonesia is mostly dependent on fuel based cars. Therefore, more fuel combustion releases more carbon in the atmosphere. Fuel based cars need to be replaced by battery operated sources and hybrid engines need to be put into action. Also, liquified gas can be used as fuel since less carbon is emitted. Such replacements will take huge time and budget but the government needs to be keen in supporting such activities (Bothet al. 2013). Electronic vehicles and hybrid engine replacement must be done within next 5 years and infrastructure development has to be done. However, immediately the old vehicles which emit the maximum carbon in atmosphere need to be replaced by new vehicles. Further use of Plug-in hybrid electric vehicles and cleaner burning gasoline vehicles will help in reducing smoke and particulate matters. Hydrogen fuel cell vehicles will help in limiting the smoke emission and therefore less sulfur and carbon will be emitted (Dirgahayani 2013). Government Initiatives and Policies National Action Plan on Climate Change Adaptation (RAN-API) will act as the guidance for providing near-term priority adaptation by the decision makers. The action plan designed by regional provinces will need to be supported by the government and subsidy needs to be provided in terms of financing. On the other hand, the government needs to take action for policy adaptation from developed countries for limiting illegal deforestation. Rules, regulations, fines and penalties needs to be designed so that none of the entities are left or given privilege. Plantation, adaptation, rainwater canal, infrastructure development and transportation technology need to be taken care by government in future. Conclusion While summing, it can be said that Indonesia can reduce its air pollution if both the government and industrialists take a positive note in improving environment. The most important reason for air pollution has been found to be deforestation and therefore it needs to be reduced by joint initiatives taken by government and industrialists. On the other hand, transportation and urbanization has to be optimized through designing policies and limiting resource consumption. 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