Dental

Caries

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Introduction:
The word caries is derived from the Latin word meaning rot or decay. Dental caries is
an irreversible microbial disease of the calcified tissues of the teeth, characterized by
demineralization of the inorganic portion and destruction of the organic substance of the tooth.

Epidemiology of Dental Caries:

Epidemiology is the study of health and disease state in populations rather than individuals.
Epidemiologists measure both the prevalence and the incidence of caries. Findings from the
Interdepartmental Committee on Nutrition for National Defence (ICNND) and WHO studies
(Barmes,1981) indicate that caries prevalence follows definite regional patterns. It is generally
lowest (0.51.7 DMF) in Asian and African countries and highest (1218 DMF) in America
and other Western countries. Consistently, low to moderate caries rates were found in
populations of the Indo-Chinese peninsula, Malaysia, central and southern Thailand, Burma,
South Vietnam, mainland China, Taiwan, India and New Guinea. Generally, highly
industrialized countries have the highest caries indices with Decayed, Missing, and Filled
Teeth (DMFT) of approximately 4.5. However, within this large group of countries a very
high caries pattern of over 5.6 DMFT occurs in New Zealand, Australia, Brazil, and Argentina.

Etiology of Dental Caries:

As we know, dental caries is a multifactorial disease of tooth which has been explained by
many theories. Though there is no universally accepted theory of the etiology of dental caries,
but following three theories are considered in etiology of dental caries:

1. Acidogenic theory
2. Proteolytic theory
3. Proteolysis-chelation theory.

1. Acidogenic Theory:
WD Miller in 1882 said Dental decay is a chemicoparasitic process consisting of two stages,
the decalcification of enamel, which results in its total destruction, as a preliminary stage
followed by dissolution of the softened residue of the enamel and dentin. In the first stage
there is destruction which is done by the acid attack whereas the dissolution of the residue
(2nd stage) is carried out by the proteolytic action of the bacterias.

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This whole process is supported by the presence of carbohydrates, microorganisms and dental
plaque.

2. Proteolytic Theory:
Heider, Bodecker (1878) and Abbott (1879) thrown considerable light to this theory.
According to this theory, organic portion of the tooth plays an important role in the
development of dental caries. It has been recognized that enamel contains 0.56 percent of
organic matter out of which 0.18 percent is keratin and 0.17 percent is a soluble protein
Enamel structure which are made of the organic material such as enamel lamella and enamel
rods prove to be the pathways for the advancing microorganisms. Microorganisms invade the
enamel lamella and the acid produced by the bacterias causes damage to the organic pathways.

3. Proteolysis-Chelation Theory:
This theory was put forward by Schatz and his coworkers in 1955. Chelation is a process in
which there is complexing of the metal ions to form complex substance through coordinate
covalent bond which results in poorly dissociated or weakly ionized compound.
Chelation is independent of the pH of the medium. Bacterial attack on the surface of the
enamel is initiated by keratinolytic microorganisms. This causes the breakdown of the protein
chiefly keratin. This results in the formation of soluble chelates which decalcify enamel even
at neutral pH. Enamel contains mucopolysaccharides, lipids and citrate which are susceptible
to bacterial attack and act as chelators.

Current Concepts of Carries Etiology:

There are four essential factors (Fig. 1) required for the development of dental caries:
1. The Host (tooth)
2. Substrate (Environmental factors)
a. Saliva
b. Diet
3. Microorganisms
4. Time period.

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1. The Host:
The structure, composition & position of
the teethundoubtedly influences the
initiation and progression of a carious
lesion. Studies on the chemical
composition enamel indicate that the
surface enamel is more resistant to caries
than subsurface enamel. The surface is
lower in carbon dioxide, dissolves at a
slower rate in acids, contains less water
and has more inorganic material than
Figure 1: Local factors affecting incidence of dental caries
subsurface enamel. Significant
differences in fluoride content of sound and carious teeth have been reported. The enamel of
sound teeth contain 0.0111 0.0020% fluoride, while that of carious teeth contain 0.0069
0.0011% fluoride.
The presence of deep, narrow occlusal fissures or buccal or lingual pits tend
to trap food, bacteria and debris, and since defects are especially common in the base of
fissures, caries may develop rapidly in these areas. Conversely, as attrition advances the
inclined planes become flattened, providing less opportunity for caries development.
Teeth are malaligned, out of position or rotated difficult to clean and tend to favor the
accumulation of food and debris which leads to caries.

2. Substrate:
a. Saliva: Saliva is the bodys natural protective mechanism against decay. It contains
salivary proteins which get deposited onto the tooth surface which help the enamel against
acid dissolution. This protective layer is referred to as the pellicle. Salivary proteins also
act as antibacterial agents. Since saliva is rich in calcium, phosphate and fluoride, these
materials help in remineralization of the enamel. Saliva acts as cleaner of teeth as it quickly
washes away food debris from the mouth and to buffer the organic acids that are produced
by the bacteria. When salivary flow is reduced or absent, there occurs the increased food
retention. Since salivary buffering capacity is lost, an acid environment is encouraged
which further promotes the growth of aciduric bacteria. These aciduric bacterias savor the
acid conditions and metabolize carbohydrates in the low-pH environment.
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b. Diet: In the earlier times, the primitive man used to eat rough and raw unrefined foods which
had self-cleansing capacity. But in present times, soft refined foods are eaten which stick
stubbornly to the teeth and are not removed easily due to lack of roughage. This is the reason
for higher incidence of dental caries now-a-days than the past. Extensive studies have shown
that foodstu or drink containing fermentable carbohydrate are likely to cause significant
acid production, followed by demineralization of the enamel, but all carbohydrates are not
equally cariogenic. Complex carbohydrates such as starch are relatively harmless because
they are not completely digested in the mouth, but low molecular weight carbohydrates
diuse readily into plaque and are metabolized quickly by the bacteria.

3. The Bacteria:
Dental caries do not occur if the oral cavity is free of bacteria. There are many types of bacteria
in the mouth, the most caries active appear to be Streptococcus mutans, Lactobacillus spp.,
Veillonella spp. and Actinomyces spp. Among these streptococci mutans are most commonly
seen microorganism associated with the dental caries. They are considered main causative
factors for caries because of their ability to adhere to tooth surfaces, produce abundant
amounts of acid, and survive and continue metabolism at low pH conditions. Colonization
with Streptococcus mutans at an early age is an important factor for early caries initiation.

4. Time Period:
The time period during which all above three direct factors, i.e. tooth, microorganisms and
substrate are acting jointly should be adequate to produce acidic pH which is critical for
dissolution of enamel to produce a carious lesion.

Classification of Dental Caries:

Carious lesions can be classified in different ways:
Based on Anatomical Site (Fig. 2):
Pit and fissure caries: Pit and fissure caries occur on occlusal surface of posterior teeth and
buccal and lingual surfaces of molars and on lingual surface of maxillary incisors.

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 Smooth surface caries: Smooth surface
caries occurs on gingival third of buccal
and lingual surfaces and on proximal
surfaces.
Root caries: When the lesion starts at
the exposed root cementum and dentin, it
is termed as root caries.

Based on Virginity of the Lesion: Figure 2: Anatomical sites of caries

Primary caries: It denotes lesions on intact surfaces.

Secondary caries (Fig. 3): Lesions
developing adjacent to fillings are
referred to as either recurrent or
secondary caries.

Based on Activity of Carious

Lesion:
Figure 3: Secondary caries
Active carious lesion: A progressive
lesion is described as an active carious lesion.
Inactive/arrested carious lesion: A lesion that may have formed earlier and then stopped
is referred to as an arrested or inactive carious lesion.

Based on speed of Caries Progression:

Acute dental caries: Acute caries travels towards the pulp at a very fast speed.
Rampant caries (Fig. 4): It is the name given to multiple active carious lesions occurring
in the same patient, frequently involving surfaces of teeth that are usually caries free. Rampant
caries is of following three types:
1. Early childhood caries: Present in the primary dentition of young children.
2. Bottle caries or nursing caries: A particular form of rampant caries in the primary
dentition of infants and young children. The clinical pattern is characteristic with the four
maxillary deciduous incisors most severely aected.

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 3. Radiation rampant caries: These are
commonly observed after radiotherapy of
malignant areas of the salivary glands. Because
of radiotherapy salivary flow is very much
reduced. This results in radiation rampant caries.
Chronic dental caries: Chronic caries travel
very slowly towards the pulp. They appear dark
in color and hard in consistency.
Figure 4: Rampant caries

Based on Treatment and Restoration Design (G.V. Black), (Fig. 5):

Class I: Pit and fissure caries occur in the occlusal surfaces of premolars and molars, the
occlusal two-third of buccal and lingual surface of molars, lingual surface of incisors.
Class II: Caries in the proximal surface of premolars and molars.
Class III: Caries in the proximal surface of anterior teeth and not involving the incisal angles.
Class IV: Caries in the proximal surface of anterior teeth also involving the incisal angle.
Class V: Caries on gingival third of facial and lingual or palatal surfaces of all teeth.
Class VI: Caries on incisal edges of anterior and cusp tips of posterior teeth without
involving any other surface.

Figure 5: G.V. Black's cavity classification

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Based on Severity (Fig. 6):
Incipient caries: It involves less than half
the thickness of enamel.
Moderate caries: It involves more than
half the thickness of enamel, but does not
involve dentino-enamel junction.
Advanced caries: It involves the dentino-
enamel junction and less than half distance to
pulp cavity.
Severe caries: It involves more than half
distance to pulp cavity.
Figure 6: Classification of caries based on severity

Based on Number of Tooth Surfaces Involved:

Simple caries: Caries involving only one tooth surface.
Compound caries: It involves more than one tooth surfaces
Complex caries: It involves more than two tooth surfaces

WHO System of Caries Classification:

This classification is based on shape and depth of carious lesion which can be scored on a four
point scale:
Scale Points Features
D1 Clinically detectable enamel lesions with intact surfaces
D2 Clinically detectable cavities in enamel
D3 Clinically detectable cavities in dentin
D4 Lesions extending into the pulp.

Histopathology of Dental Caries:

Enamel Caries:
Caries of enamel initiates by deposition of dental plaque on tooth surface. We will discuss the
carious process of the enamel according to its location on tooth surface, i.e. smooth surface
caries, and pit and fissure caries.

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 1. Smooth Surface Caries:
The first change seen histologically is the loss of interprismatic/interrod substance of
enamel with increased prominence of the rods.
There is also accentuation of the incremental lines of Retzius.
This is followed by the loss of mucopolysaccharides in the organic substance.
As it goes deeper, the caries forms a triangular pattern or cone shaped lesion with the
apex towards DEJ and base towards the tooth surface.
Finally there is loss of enamel structure, which gets roughened due to demineralization,
and disintegration of enamel prisms.

2. Pit and Fissure Caries:

Here the caries follows the direction of the enamel rods.
It is triangular in shape with the apex facing the surface of tooth and the base towards
the DEJ.
When reaches DEJ, greater number of dentinal tubules are involved.
It produces greater cavitation than the smooth surface caries and there is more
undermining of enamel.
When undermined enamel fractures, it causes exposure of cavitation and caries.

3. Zones in Enamel Caries (Fig. 7):

Different zones are seen before
complete disintegration of enamel.
Early enamel lesion seen under
polarized light reveals four distinct
zones of mineralization. These zones
begin from the dentinal side of the
lesion.
Zone 1: Translucent zone
Figure 7: Zones of enamel caries
Represent the advancing front of the lesion
Ten times more porous than sound enamel
Not always present.

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 Zone 2: Dark zone
It lies adjacent and superficial to the translucent zone
Usually present and thus referred as positive zone
Called dark zone because it does not transmit polarized light
Formed due to demineralization.
Zone 3: Body of the lesion
Largest portion of the incipient caries
Found between the surface and the dark zone
It is the area of greatest demineralization making it more porous.
Zone 4: Surface zone
This zone is not or least affected by caries
Greater resistance probably due to greater degree of mineralization and greater fluoride
concentration
It is less than 5 percent porous
Its radiopacity is comparable to adjacent enamel.

Dentinal Caries:
1. Early Dentinal Changes:
Initial penetration of the dentin by caries causes an alteration in dentin, known as
dentinal sclerosis.
In this reaction there occurs the calcification of dentinal tubules which seals off from
further penetration by microorganisms.
When dentinal tubules are completely occluded by the mineral precipitate, section of
the tooth gives a transparent appearance in transmitted light, this dentin is termed as
transparent dentin.
In the earliest stages, when only few tubules are involved, microorganisms may be
found penetrating the tubules, called Pioneer Bacteria.
In early caries, fatty degeneration of Tomes fibers and deposition of fat globules in
these processes act as predisposing factor for sclerosis of the tubules.
This initial decalcification involves the walls allowing them to distend as the tubules
are packed with microorganisms. Each tubule is seen to be packed with pure forms of
bacteria, e.g. one tubule packed with coccal forms the other tubule with bacilli.

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 As the microorganisms proceed further they are distanced from the carbohydrates
substrate that was needed for the initiation of the caries.
Thus the high protein content of dentin must favor the growth of the microorganisms.
Therefore, proteolytic organisms might appear to predominate in the deeper caries of
dentin while acidophilic forms are more prominent in early caries.

2. Advanced Dentinal Changes:

In advanced lesion, decalcification of the wall of the individual tubules takes place,
resulting in confluence of the dentinal tubules.
Sometimes the sheath of Neumann shows swelling and thickening at irregular intervals
in the course of dentinal tubules.
The diameter of dentinal tubules increases because of packing of microorganisms.
There occurs the formation of tiny liquefaction foci, described by Miller. They are
formed by the focal coalescing and breakdown of dentinal tubules. These are ovoid
areas of destruction parallel to the course of the tubules which are filled with necrotic
debris and increase in size by expanding. This expansion produces compression and
distortion of adjacent dentinal tubules, leading to course of dentinal tubules being bent
around the liquefaction focus.
The destruction of dentin by decalcification and then proteolysis occurs in numerous
focal areas. It results in a necrotic mass of dentin with a leathery consistency.
Clefts occur in the carious dentin that extends at right angles to the dentinal tubules.
These account for the peeling off of dentin in layers while excavating.
Shape of the lesion is triangular with the apex towards the pulp and the base towards
the enamel.

3. Zones of Dentinal Caries (Fig. 8):

Five zones have been described in dentinal caries. These zones are clearly distinguished
in chronic caries than in acute caries. These zones begin from the pulpal side:
Zone 1: Normal dentin
Zone of fatty degeneration of Tomes fibers
Formed by degeneration of the odontoblastic process
Otherwise dentin is normal and produces sharp pain on stimulation.
Zone 2: Zone of dentinal sclerosis
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 Intertubular dentin is demineralized
Dentinal sclerosis, i.e. deposition of calcium
salts in dentinal tubules takes place
Damage to the odontoblastic zone process is
apparent
There are no bacteria in this zone. Hence, this
zone is capable of remineralization.
Zone 3: Zone of decalcification of dentin
Further demineralization of intertubular dentin
lead to softer dentin.
Zone 4: Zone of bacterial invasion
Figure 8: Zones of dentinal caries
Widening and distortion of the dentinal tubules
which are filled with bacteria
Dentin is not self-repairable, because of less mineral content and irreversibly denatured
collagen.
This zone should be removed during tooth preparation.
Zone 5: Zone of decomposed dentin due to acids and enzymes
Outermost zone
Consists of decomposed dentin filled with bacteria
It must be removed during tooth preparation.

Diagnosis:
In order to conserve tooth structure and perform minimally invasive dentistry, carious lesions
must be detected at the earliest possible time. By doing so, caries progress can be arrested,
thus avoiding a more invasive operative intervention. Various methods for diagnosis of dental
caries are:
1. Visual-tactile method
a. Conventional methods
i. Tactile examination
ii. Visual examination.
b. Advances in visual method
i. Illumination
Ultrasonic illumination
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 Ultrasonic imaging
Fiber-optic trans-illumination (FOTI)
Wavelength dependent FOTI
Digital imaging FOTI (DIFOTI).
ii. Dyes
iii. Endoscopy filtered fluorescence (EFF).
2. Radiographic methods
a. Conventional methods
i. Intraoral periapical X-rays (IOPA), (Fig. 9) Figure 9: Radiograph showing occlusal caries

ii. Bitewing radiographs

iii. Panorex radiography
iv. Xeroradiography.
b. Recent advances in radiographic techniques
i. Digital imaging
ii. Computerized image analysis
iii. Substraction radiography
iv. Tuned aperture computerized
tomography (TACT)
v.Magnetic resonance
microimaging (MRMI).
3. Electrical conductance measurement
4. Lasers
a. Argon laser
Figure 10: QLF technique for detecting dental caries
b. Diode lasers
c. Qualitative laser fluorescence
d. Diagnodent (Quantitative laser fluorescence), (Fig. 10)
e. Optical coherence tomography
f. Polarization sensitive optical coherence tomography (PSOCT)
g. Dye enhanced laser fluorescence.

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Prevention of Dental Caries:
Method of dental caries control can be classified into two main types:
A. Methods to reduce demineralizing factors:
1. Dietary measures:
a. Sugar substitutes: Xylitol is a five-carbon sugar alcohol with the taste almost identical
to that of table sugar. It is non fermentable, non-cariogenic sugar and has anti-caries effects.
b. Fibrous food: Intake of raw fruits, vegetables and grains helps in increasing the salivary
flow, thereby removal of food debris from the oral cavity. These foods contain natural
phosphates, phytates and non-digestable fibers, moreover they do not stick to teeth, thus
increases caries protective mechanism.
c. Cheese: Cheese is considered as responsible for Increasing the salivary flow, pH, and
Promoting the clearance of sugar. All these factors help in reducing the incidence of caries.

2. Methods to improve oral hygiene:

a. Dental prophylaxis: polishing of roughened tooth surfaces and replacement of faulty
restorations is done so as to decrease the formation of dental plaque, therefore, resulting in
less incidence of caries.
b. Tooth brushing: Nowadays, tooth brushing and other mechanical cleaning procedures
are considered to be the most reliable means of controlling plaque and provide clean tooth
surface.
c. Interdental cleaning: Regular Flossing of interdental spaces reduce the probability of
proximal and root caries

3. Chemical measures:
Substances interfering with carbohydrate degradation through enzymatic alterations:
Vitamin K, Sarcocide
Substances interfering with bacterial growth and metabolism: Chlorhexidine, Iodine,
Urea and ammonium compounds, Nitrofurans.

B. Methods to increase protective factors:

1. Methods to improve flow, quantity and quality of saliva: Patients with
hyposalivation, baking soda may help to neutralize acids.
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The mouth rinse is prepared by mixing two teaspoons of baking soda in eight oz of water.
This solution is used for mouth rinsing after eating.

2. Chemicals altering the tooth surface or tooth structure:

Fluorides: To increase the resistance of tooth structure to demineralization, small amounts of
fluoride should be added. Fluoride ions increase the resistance of the hydroxyapatite in
enamel and dentin to dissolution by plaque acids, Inhibits demineralization, Induces re-
mineralization, Inhibits bacterial metabolism and plaque formation. So, fluoride is considered
as important component in caries prevention. The good source of fluoride in human diet
includes: Potatoes, Bananas, Tea leaves, Rock salt, Salmon and sardines.

3. Application of remineralizing agents:

Remineralizing agents are available in various forms like dentifrices, mouthwashes, chewing
gums, lozenges, and foods and beverages. Commonly used agents are calcium glycerol-
phosphate and calcium lactate, dicalcium phosphate dehydrate (DCPD), and calcium
carbonate. Recently, casein phosphopeptide (CPP), amorphous calcium-phosphate (ACP)
complexes have also been considered as agents for remineralization. Because of high
solubility and ability to rapidly hydrolyze to form apatite, amorphous calcium phosphate
agents (ACPs) come under good source for tooth remineralization.

4. Use of pit and fissure sealants:

A pit and fissure sealant is a material that is placed in the pits and fissures of teeth in order
to prevent or arrest the development of dental caries. For better eects, sealants should be
placed as soon as possible because of more susceptibility of caries during the post-eruption
period.

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Apicoectomy

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Introductions:
An Apicoectomy is a minor oral surgical procedure to remove the tip of the apex of the root
of a dead tooth and associated pathological lesions and then seal the root end with a filling. It
is commonly performed to remove a portion of the root with undbrided canal space or to seal
the canal apically when a complete seal cannot be accomplished with nonsurgical root canal
treatment through the crown approach. The typical sequence of procedures used in
Apicoectomy are Anesthetization, flap design, incision and reflection, apical access,
periradicular curettage, root-end resection, root-end cavity preparation, root-end filling, flap
replacement, suturing and suture removal.

Indications:
Inability to perform nonsurgical endodontic therapy due to anatomical, pathological
and iatrogenic defects in the root canal.
Persistent infections after conventional endodontic treatment.
Need for biopsy.
Need to evaluate the resected root surface for any additional canals or fracture.
For removal of iatrogenic errors like ledges, fractured instruments, and perforation
which are causing treatment failure.
Removal of the un-instrumented and unfilled portion of the root.
Blockage of the root canal due to calcific metamorphosis or radicular restoration.
Severe root curvature.
Horizontal fracture at the root tip with associated periapical disease.

Contraindications:
Local Factors:
Inaccessibility to surgical site because of tooth location
Tooth position adjacent to the spaces such as maxillary sinus or nasal fossa
Unusual bony configuration
Short root length in which removal of root apex further compromises the prognosis.
Proximity to the neurovascular bundles
Severe periodontal diseases.

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 Vertically fractured tooth

Systemic Factors:
Leukemia or neutropenia in active state leading to more chances of infection after
surgery, and impaired healing
Uncontrolled diabetes mellitus: Defective leukocyte function, defective wound
healing commonly occurs in severe diabetic patients
Recent serious cardiac or cancer surgery
Very old patients: Old age is usually associated with complications like cardiovascular
or pulmonary disorders, decreased kidney functions and liver functions.
Uncontrolled hypertension
Uncontrolled bleeding disorders
Immunocompromised patients
Recent myocardial infarction or patient taking anticoagulants

Local Anesthesia and Hemostasis:

The selection of an appropriate anesthetic agent should always be based on the medical status
of the patient and the desired duration of anesthesia needed. The injection of a local anesthetic
agent that contains a vasoconstrictor has two
equally important objectives:
(1) To obtain profound and prolonged
anesthesia and
(2) To provide good hemostasis both
during and after the surgical procedure
In medically compromised patient LA without
adrenaline should be given to avoid complication
during and after surgical procedure.

Flap Design (Fig. 11):

The first step in Apicoectomy is designing a flap Figure 11: Flap design

that allows adequate exposure to the surgical site

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of the surgery for the operator. The following general guidelines and principles should be used
during flap design:
The flap should be designed for maximum access to the site of surgery.
Adequate blood supply to the reflected tissue is maintained with a wide flap base.
Avoid severely angled vertical incision
Incisions over bony defects or over the periradicular lesion should be avoided; these
might cause postsurgical soft tissue fenestrations or nonunion of the incision.
The actual bony defect is larger than the size observed radiographically.
A minimal flap, which should include at least one tooth on either side of the intended
tooth, should be used.
Acute angles in the flap must be avoided. Sharp corners are difficult to reposition and
suture and may become ischemic and slough, resulting in delayed healing and possibly
scar formation.
Incisions and reflections include periosteum as part of the flap. Any remaining pieces
or tags of cellular nonreflected periosteum will hemorrhage, compromising visibility.
The interdental papilla must not be split (incised through) and should be either fully
included or excluded from the flap.
Vertical incisions must be extended to allow the retractor to rest on bone and not crush
portions of the flap.

Incision and Reflection (Fig. 12):

A firm incision is made with a CK-2, CK-3 or
other suitable blade into the base of the sulcus or
initiation of the horizontal incision. To prevent
tearing during reflection, the incision must be
made through periosteum to bone. Once the
horizontal incision has been made, the same blade
or a No. 15 can be used to place the vertical
Figure 12: Reflection of flap with periosteal elevator
incision. The tissue is reflected with a sharp
periosteal elevator. Because periosteum is reflected as part of the flap, the elevator must firmly
contact bone as the tissue is relieved, using firm controlled force. The tissue is reflected
beyond the mucogingival junction to a level that will provide adequate access to the root apex,
provide visibility of the surgical site and allow a retractor to be placed on sound bone.
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Osteoectomy:
In many cases, the presence of a periradicular lesion
creates a defect in the cortical bone that is visible
after flap reflection or is identified when firm
probing with an explorer is applied on the bone. If
the opening is small, a sharp round bur can be used
to remove the bone (Fig. 13) until the apex is located.
If there is limited cortical bone destruction, after
Figure 13: Removal of bone by round bur
placement of a radio opaque object near the apex, a
radiograph should be taken to locate the apex. Removal of bone with a bur is performed by a
light brushing motion in the presence of copious sterile saline irrigation.

Periradicular Curettage:
The tissue should be carefully peeled out, ideally in
one piece, with a suitably sized sharp curette (Fig. 14).
This process should leave a clean bony cavity. When
the lesion is very large, portions of tissue can be left
without compromising the blood supply to an adjacent
tooth. This should not affect periradicular healing.
Figure 14: Periapical curette

Root-End Resection (Fig. 14):

Root-end resection involves beveling the apical
portion of the root. This step is an integral part of
apicoectomy and serves the following purposes:
It removes the untreated apical portion of the
root and enables the operator to determine
the cause of failure.
It provides a flat surface to prepare a root-
end cavity preparation and pack it with a Figure15: Root end resection done by fissure bur
root-end filling material.
Apical sectioning is done with a tapered fissure bur in a high-speed handpiece and copious
sterile saline irrigation. The bevel should be made at as close to 00 in a faciolingual direction

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as possible to still enable maximum visibility to the root apex. In general, the amount of root
removed depends on the reason for performing the root-end resection.
However, sufficient resection must be performed to expose additional canals, apical deltas, or
fractures.

Root-End Cavity Preparation and Filling:

Apical preparations are made with ultrasonic tips. A variety of tips are available to
accommodate virtually all access situations. When used, they are placed in the long axis of
the root so that the walls of the preparation will be parallel with long access of the root. A
class I type preparation is made with ultrasonic tips (Fig. 16) to a minimum depth of 3 mm
into the canal. More complicated apical root anatomy may require other types of preparation.
The ultrasonic instrument offers advantages of
control and ease of use and permits less apical
root beveling and uniform depth of preparation.
In addition, the ultrasonic tips produce smaller
apical preparations, allow easier preparation of
isthmus, follow the direction of the canals, clean
the canal surfaces better than burs, and create less
fatigue for the operator. Though round bur also
can be used for preparation after the apical
preparation is made and thoroughly examined, it Figure16: Root end preparation with ultrasonic tips

should be filled with a root-end filling material (Fig. 17). Root-end filling materials should be:
Well tolerated by periapical tissues
Adhere to tooth surface
Dimensionally stable
Resistant to dissolution
Bactericidal or bacteriostatic
Not stain tooth or periradicular
tissue
Radiopaque.
Figure17: Placement of restorative materials
after cavity preparation

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Many materials have been used as root-end filling materials. Commonly used root-end filling
materials are Amalgam, Gutta-percha, Gold foil, Titanium screws, Glass ionomers, Zinc
oxide eugenol, Cavit, Composite resins, Polycarboxylate cement, Poly HEMA, Super
EBA, Mineral trioxide aggregate.

Flap Replacement and Suturing (Fig. 18):

After placing a root-end filling material and taking a radiograph, the flap should be placed in
its original position and held in place for 5 minutes using moderate digital pressure with
moistened gauze. This allows expression of hemorrhage from under the flap, initial adaptation,
easier suturing, and less postoperative swelling and bleeding. There are many suturing
techniques, including interrupted, continuous mattress, and sling sutures. Interrupted sutures
are commonly used. When suturing, the needle passes first through reflected and then through
attached tissue. The sutures are tied with a simple double surgeons knot. The knot should not
be placed over the incision line because it collects debris and bacteria that will promote
inflammation, infection, and delayed healing. The sutures are usually removed 3 to 7 days
after surgery.

Figure18: Flap replacement and suture placed

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 Basic Instruments
used in Oral Surgery

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Instrument Used for Preparing The
Surgical Field:
Swab Holder (Fig. 19):
It is an instrument with long blades, expanded at the
ends, forming an oblong tip. The blades have a central
Fenestration and transverse serrations.
Uses:
1. To hold a swab and clean the area of operation.
2. To swab the throat when there are profuse secretions
in a patients under general anesthesia. Figure19: Swab Holder

Instrument Used for Incising The Tissues:

Scalpel:
The instrument used for making an incision is called a scalpel. The scalpel has two parts, a
blade and a blade handle.
1. Bard Parker Blade Handle (Fig. 20.A): Various sizes of the handles are available. The
most commonly used handle in oral surgery is no. 3. The handle has a receiving slot for
the blade. While fitting the blade to the blade handle, it is held with the help of a needle
holder or an artery forceps to prevent injury to the operator. The blade is then pushed into
the slot till it fits in snugly. The scalpel is always used in the pen grip.

2. Blades:
No. 10 (Fig. 20.B) For making
skin incisions
No. 11 (Fig. 20.C) For making
stab incisions (to drain an abscess)
No. 12 (Fig. 20.D) For
mucogingival procedures
No. 15 (Fig. 20.E) For
intraoral surgery.
Figure20: (A) Bard Parker Blade Handle (B) No.10 Blade (C) No.11 Blade
(D) No.12 Blade (E) No. 15 Blade (F) Dissecting Scissors

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Dissecting Scissors (Fig. 20.F):
As the name suggests, dissecting scissors are used to perform soft tissue dissection in the
deeper layers. The scissors have a blunt nose for undermining the tissues and a side cutting
edge for cutting the tissues.

Instrument Used for Retracting Tissues:

Langenbecks Retractor (Fig. 21.A):
It has a long handle and an L shaped blade. This retractor is most commonly used in oral
surgery. It is available in different sizes and blade width. The instrument can be single or
double ended. It is used to retract the soft tissues, incision edges, to allow view of the deeper
structures.

Obwegesers Ramus Retractor (Fig. 21.B.C):

The retractor is similar to the Langenbecks retractor except that the edge of the retracting
blade is forked, forming a V shaped notch, so as to engage the anterior border of the ramus
of the mandible and aid in good tissue retraction. It is used to retract the soft tissues along the
anterior border of the ramus during sagittal split, ramus osteotomy or coronoidectomy
procedures.

Condyle Retractor (Fig. 22.B):

They are special retractors that have
an appearance similar to the tongue
depressor, but are narrower and the tip
of the blade has a C shaped hook that
is slipped under the ankylosed mass to
retract and protect the medial soft
tissues during release of the ankylosis.
Figure 21: (A) Langenbecks retractor, (B and C) Obwegesers
ramus retractors

Cat Paw Retractor (Fig. 22.C):

As the name suggests, the instrument resembles a catspaw. The blade has prongs that are
curved at the tip. It is used to retract small amounts of soft tissue.

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Tongue Depressor (Fig. 22.D):
The tongue depressor is an L shaped
instrument with a broad smooth blade for
depressing or retracting the tongue.

Figure 22: (B) Condyle retractor, (C) Cat Paw retractor,

(D) Tongue depressor

Instrument Used for Reflecting The Mucoperiosteal Flap:

Moons Probe (Fig. 23.A):
It is a thin, flat instrument that has a small working tip at right angles to the handle. The tip is
narrow and sharp. It is used to elevate the attached gingiva around the tooth prior to extraction.

Periosteal Elevators (Fig. 23.B-E):

As the name suggests these instruments are used for reflecting the mucoperiosteum. Most of
the periosteal elevators have a broad end on one side and a pointed or triangular end on the
other.
Uses:
1. The pointed end is used to release the
interdental papillae.
2. The broad end is used for elevating the
mucoperiosteal flap from the bone.
3. The broad end can also be used as a soft
tissue retractor.

Cleft Palate Raspatory (Fig. 23.F):

This broad, flat handled elevator is
specially used to elevate the palatal
mucoperiosteum while mobilizing the Figure23 :(A) Moons probe, (B to E) Periosteal elevators, (F)
Cleft palate raspatory
flaps for cleft palate repair.
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Instrument Used for
Holding The Soft Tissues:
Tissue Holding Forceps:
As the name suggests these are used
to hold the soft tissues of the body.

1. Allis Tissue Holding Forcep

(Fig. 24.A): It is a short
instrument, with a catch and the
blades have teeth that are delicate.
Figure 24: (A) Allis tissue holding forceps, (B) Babcocks tissue
Uses.
Holding forceps, (C) Lanes tissue holding forceps
1. To hold delicate tissues like the
peritoneum, aponeurosis, soft muscles
2. To retract and hold the tissue margins and skin edges.
3. To provide tension for tissue dissection.

2. Babcocks Tissue Holding Forcep (Fig. 24.B): It has fenestrated blades without
teeth. It is used to hold enlarged lymph nodes or any glandular tissue.

3. Lanes Tissue Holding Forcep (Fig. 24.C): It is a long and stout instrument with
sharp teeth on the blades. It is used to hold tough structures like the skin, coarse muscles.

Hemostatic Forceps (Fig. 25):

They are used to catch hold of bleeding
vessels. The unidirectional, transverse
serrations on the blades of the hemostat
prevent the vessel from slipping. The
vessel is crushed between the blades and
hemostasis is achieved. The handle has a
Figure 25: Hemostatic Forcep
catch and the vessel may be held and
clamped. Small bleeders may be controlled by just crushing the vessel, whereas bigger vessels
may be cauterized or ligated.
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Instrument Used to Keep The Mouth Open:
Mouth Prop (Fig. 26.A):
The function of the mouth prop is
to keep the mouth open during
any surgical procedure performed
in the oral cavity. The mouth prop
consists of a vertical block having
a concave surface on either of its
ends to fit on the occlusal surfaces
of maxillary and mandibular
teeth. The block is placed Figure 26: (A) Metal mouth prop, (B) Heisters jaw stretcher, (C)
Fergussons mouth gag
between the mandibular and
maxillary teeth to maintain the mouth open. Usually, there are three or four blocks of varying
vertical heights arranged in an ascending order, and connected by a chain. The operator can
choose the block according to the required extent of oral opening.

Heisters Jaw Stretcher (Fig. 26.B):

The instrument has two flat blades that are applied between the maxillary and mandibular
posterior teeth and are separated by turning a key that is positioned between the two blades.
Uses:
1. To force the mouth open when there is trismus due to infection, muscle spasm, hemarthrosis
of the temporomandibular joint following trauma.
2. To give postoperative active jaw physiotherapy after surgery for TM joint ankylosis or
submucous fibrosis.

Mouth Gag (Fig. 26.C):

This instrument is used to keep the mouth open in a patient under general anesthesia, during
surgeries of the oral cavity, tonsils and the pharynx. The flat blades have serrations that rest
on the occlusal surfaces of the maxillary and the mandibular teeth. The handle has a catch that
is fixed at the required opening.

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Instrument Used to Remove Pathologic Tissues:
Curette (Fig. 27.B.C):
A curette can be single ended or
double ended. The working end may
be in the same plane as the shank or
at an angulation for adequate access
to the pathologic cavity. It is used to
remove tooth particles or debris from
the extraction socket and to enucleate
cysts, periapical granulomas,
intraosseous tumors. Figure 27: (B and C) Lucas curettes, (D) Volkmanns scoop

Volkmanns Scoop (Fig. 27.D):

It is similar to a curette, but the concavity of the working edges is more pronounced. It is used
to collect specimen from a sinus tract, chronic abscess cavity or a fistula and to introduce graft
material, antiseptic powder into the surgical area.

Instrument Used to Hold The Bone:

Crocodile Bone Holding Forceps (Fig. 28.A.B):
They are named so because of the appearance of the beaks sideways. The beaks have toothed
margins to allow a good grip on the bone. The Crocodile bone holding forceps has a catch to
stabilize the instrument in the required position. It is used to hold the bony fragments of the
mandible during manipulation of the bony fragments during fracture reduction, resection
procedures, after osteotomy cuts, and during fixation of the bony fragments.

Instrument Used to Cut or Remove Bone:

Rongeurs Forceps (Fig. 28.C):
The rongeurs forceps have curved handles that have a spring action. The spring increases the
force applied and hence efficiency of the instrument. When the handles are released the
instrument automatically opens up. This helps the surgeon to make repeated cuts without
making efforts to open the handles. The tip is angulated forward to the handle and has a

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concave inner surface. The beaks are sharp. They can be either side cutting (Blumenthal) or
both side and end cutting.
Uses:
1. To nibble sharp bony margins following simple or surgical extraction of teeth, surgical
procedures
2. To peel off thinned out bone present over cystic or tumorous lesions.

Miller and Colburn Bone File (Fig. 28.D):

The instrument has a long
curved working end and a short
oval working end. The working
ends have horizontal serrations.
The instrument is activated by
spring action. The edges of the
blades are sharp and have a side
cutting action. It is used to trim
sharp bony margins following
extractions, minor oral surgical
procedures and to trim sharp
ridge projections during
alveoloplasty procedure. Figure 28: (A and B) Crocodile bone holding forceps, (C) Jensen
Middleton Rongeurs forceps, and (D) Miller and Colburn bone le

Chisels (Fig. 29.B.C.D):

It have a heavy round handle and a long flat working tip. The edge of the working tip has a
bevel on one side. The working edge is sharp and is flat. It is used to remove chips of bone as
in transalveolar extractions and to split the tooth in difficult extractions.

Osteotome (Fig. 29.A):

The osteotome is similar to a chisel, but the edge of the working tip is bi-beveled. It splits
bone rather than cut or chip the bone as with the chisel.

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Bone Gouge (Fig. 29.E):
The bone gouge has a round handle and a blade that has a sharp working tip that is concave
on the inner side. It is used to remove cancellous graft material during grafting procedures and
irregular pieces of bone.

Mallet (Fig. 29.F):

A mallet is made up of steel, lead or wood. It is similar to a hammer and is used for giving
controlled taps on the chisel, bone gouge or osteotome. To be effective, the mallet should be
used with a loose, free swinging movement of the wrist that gives maximum speed to the head
of the mallet. Usually a six inch mallet is used for minor oral surgical procedures.

Figure 29: (A) Osteotome, (B to D) Chisels, (E) Bone gouge, (F) Mallet

Hand Piece & Burs:

It is a quicker method of bone removal by drilling the bone at high speeds. Burs are rotary
instruments that cut the bone. They are made up of either stainless steel or carbide. They are
available in different lengths, shapes and sizes.
Uses:
1. To round of sharp margins after extractions, alveoplasty and minor surgical procedures.
2. To aid in bone removal or splitting the tooth, during disimpaction procedure.
4. To perform osteotomy cuts.

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Instrument Used for Suturing:
Mayo-Hegar Needle Holder (Fig. 30.A): The
needle holder is a straight instrument with a short
working tip. The working tip has cross hatched
serrations with a single vertical serration to grip the
needle. The handle has a catch. Usually a six inch
needle holder is used in Oral Surgery. The instrument
is held between the ring finger and the thumb and the
index and the middle finger support the needle holder.

Suture Cutting Scissors (Fig. 30.B):

Figure 30: (A) Mayo-Hegar needle holder,
They are used for cutting the suture ends. They can be
(B) Deans suture cutting scissors
straight or curved, and angulated or nonangulated.
They have long delicate handles and a short cutting edge.

Instruments Used for Tooth Extraction:

Elevators (Fig. 31):
The dental elevators are used to luxate the
teeth from the socket prior to application of
the forceps. In addition to luxation of the
teeth, the elevators also expand the bony
socket facilitating tooth extraction. They
are also used to remove root remnants from
the extraction socket. The elevator has
three components:
1. Handle, 2. Shank, 3. Blade.
Types of Elevator:
1. Straight Elevator 2. Cryers Elevator 3.
Figure 31: Elevators
Winters Elevator 4. Winter Cryers

Elevator 5. Apexo Elevator

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Forceps:
They are designed to deliver the teeth from the sockets. Each forceps has two handles, a joint
and two beaks. All the forceps have crosshatching on the handles to allow a firm grip and have
serrations on the inner side of the beaks to allow a better grip on the tooth. The beaks are
applied along the long axis of the tooth, below the CE junction in mandibular teeth, and above
the CE Junction in maxillary teeth. A firm grip on the tooth is established prior to giving any
forceps movements.

Types of Forceps:
1. Maxillary Extraction Forceps (Fig. 32)
a. Maxillary anterior forceps
b. Maxillary premolar forceps
c. Maxillary molar forceps
d. Maxillary anterior root forceps
e. Maxillary posterior root forceps
f. Bayonet forceps Figure 32: Maxillary Extraction Forceps
2. Mandibular Extraction Forceps (Fig. 33)
a. Mandibular anterior forceps
b. Mandibular premolar forceps
c. Mandibular molar forceps
d. Mandibular root forceps

Figure 33: Mandibular Extraction Forceps

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References:

1. Nisha Garj, Amit Garj. Textbook of Operative Dentistry, 2nd ed.; Chapter-25
2. R. A. Cawson, E. W. Odell Oral Pathology and Oral Medicine, 8th ed.; Chapter-3
3. R. Rajendran, B. Sivapathasundaram. Shafers Textbook of Oral Pathology, 6th ed.;
Chapter-9
4. Textbook of Endodontics by Nisha Garj, Amit Garj; Chapter-25
5. Ingles Endodontics; Chapter-33
6. T. R. Pitt Ford. Hartys Endodontics in Clinical Practice, 5th ed; Chapter-9
7. Louis I. Grossman, Seymour Oliet, Carlos E. Del Rio. Endodontic Practice, 11th
ed.; Chapter-17
8. Prof. Dr. Neelima Anil Malik. Textbook of Oral and Maxillofacial Surgery, 3rd ed.;
Chapter-5
9. S.M Balaji. Textbook of Oral and Maxillofacial Surgery; Chapter-4
10. Dr. Vinod Kapoor. Textbook of Oral and Maxillofacial Surgery, 2nd ed.; Chapter-
1
11. Gustav O. Kruger. Textbook of Oral and Maxillofacial Surgery, 6th ed.; Chapter-3

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