Beruflich Dokumente
Kultur Dokumente
A c o m pl
plee t e n o te fo
forr th
thee fi
finn al ye
yeaa r M BB
BBS
S
T ABLE OF CONTENTS
Table Of Contents ..........
.....................
......................
......................
......................
............. 1
Introduction to Dentistry ..........
.....................
......................
......................
............. 2
Oral Cavity ................................................................. 2
Development of Teeth ...........
......................
......................
......................
...............
.... 3
Dental Anatomy ......................................................... 5
Human Dentition...........
......................
......................
......................
......................
............. 6
Clinical dental notation ............................................ 10
Oral Hygiene ............................................................ 11
Dental plaque ........................................................... 15
Dental calculus ......................................................... 17
Dental Caries ............................................................ 18
Periodontal diseases and Gingivitis..........
.....................
.................
...... 22
Periodontitis ............................................................ 25
Dentoalveolar Abscess and Periodontal Abscess ....... 27
Impacted Teeth ........................................................ 28
Pericoronitis ............................................................. 29
Pulpitis ..................................................................... 30
Malocclusion ............................................................ 33
Chronic Injuries to Teeth .......................................... 34
Dislocation of Temporomandibular Joint ............ ...... 37
Anesthetization ........................................................ 38
Tooth Extraction ....................................................... 43
Tooth Filling ............................................................. 45
Pulp Capping ............................................................ 46
Root Canal Treatment .............................................. 47
Maxillofacial Injuries ................................................ 48
Mandibular Fractures ............................................... 49
Maxillary Fractures..........
.....................
......................
......................
...................
........ 52
Oral Cancer .............................................................. 54
Cysts of Orofacial Region ..........
.....................
......................
.....................
.......... 56
Instruments .............................................................. 58
FAQ Examination
Caries- Very FAQ Middle third fracture Hypersensitive tooth: pulpitis
Mandible Nerve supply: inferior alveolar nerve Fluoride toothpaste - FAQ
Tooth extraction Dental hygiene: tooth brushing - Medical assessment of dental
Dentine FAQ procedure
Gingivitis vs periodontitis - Very Very Dental notation Calculus and plaque
FAQ Dentigerous cyst Dentoalveolar abscess
Antibiotics prophylaxis
prophylaxis in ie and rhd Chronic injuries - FAQ Pericoronitis
Eruptions date for deciduous permanent False and true pocket
dentition – FAQ
FAQ Examination
Caries- Very FAQ Middle third fracture Hypersensitive tooth: pulpitis
Mandible Nerve supply: inferior alveolar nerve Fluoride toothpaste - FAQ
Tooth extraction Dental hygiene: tooth brushing - Medical assessment of dental
Dentine FAQ procedure
Gingivitis vs periodontitis - Very Very Dental notation Calculus and plaque
FAQ Dentigerous cyst Dentoalveolar abscess
Antibiotics prophylaxis
prophylaxis in ie and rhd Chronic injuries - FAQ Pericoronitis
Eruptions date for deciduous permanent False and true pocket
dentition – FAQ
ORAL C AVITY
• Functions of the Oral Cavity
o Mastication
o Articulation of Speech
o Partial Digestion
o Accessory air passage
o Deglutition
o Sometimes defense
• Boundaries of the Oral Cavity
o Anteriorly: Lips
o Laterally: Buccal
o Posteriorly: Palatoglossal Fold
o Roof: Palate
o Floor: Occupied by the tongue
• The roof consists of the hard palate and soft palate
o Seven folds of mucosa called rugae: help in deglutition
o Nerves:
Nasopalatine Nerve: through incisive canal (seen as incisive papilla)
Greater palatine nerve: greater palatine foramen
Lesser palatine nerve: lesser palatine foramen.
• The floor
o Structures: Tongue, sublingual papilla, lingual frenulum, sublingual fold, deep lingual veins.
• Frenula or Frena (singular: frenulum)
o Superior labial frenulum, inferior labia frenulum.
o Lingual frenulum.
o Labial and buccal frenula.
2. Cap Stage
• Invagination of dental bud by the mesenchyme
• 2 layers: outer and inner dental epithelium
• Central core of loosely woven tissue called stellate reticulum
• Mesenchyme which originates in neural crest forms the dental papilla
3. Bell stage
• Mesenchymal cells of dental papilla adjacent to inner dental layer differentiate into odontoblasts which
later produces dentin
• Odontoblast layer persists throughout life and produces predentin
• Remaining cells of dental papilla form the pulp of the tooth
• Epithelial cells of inner dental epithelium differentiate into ameloblasts (enamel formers): form enamel
that is deposited over dentin
• A cluster of these cells in the inner dental epithelium forms enamel knot: regulate early tooth development
• Enamel is first laid down at the apex of tooth then spreads toward the neck
P ARTS OF TOOTH
• Crown
• Cervical Line
• Root
SURFACES OF TOOTH
1. Mesial surface: Towards the midline along the arch
2. Distal surface: Away from the midline along the arch
3. Facial surface: i) Labial surface (anterior teeth) or ii) Buccal surface (posterior teeth)
4. Lingual surface: In maxillary teeth, it is also called as the palatal surface
5. Occlusal surface (poorly defined in anterior teeth, incisal edge)
DENTAL ARCHES
• Maxillary/ upper arch
• Mandibular/ lower arch
CLASSIFICATION OF TEETH
Incisors Blunt, knife edge like, cut food particles (4 surfaces+1 cutting edge)
1 root
Prominence on the lingual surface of anterior teeth is known as the cingulum, more prominent
in the maxillary anterior teeth.
Canines Pointed Edge(cusp), pierce meat, small size in F (4 surfaces + 1 cusp)
(Cuspid) 1 root
Premolars Intermediate function of canines and molars (5 surfaces ) have 2 cusps: buccal cusp and lingual
(Bicuspids) cusp (also called palatal cusp in maxillary premolars)
st
2 roots (buccal and palatal) in 1 maxillary premolars, all others have 1 root
Molars Elevated parts called cusps, Depressed parts called fossae. Grinds Food (5cusps + fossae + 5
surfaces)
st
• Maxillary molars: 4 cusps (mesiolingual. distolingual, mesiobuccal, distobuccal) but 5 in 1
molar (extra cusp known as cusp of Carrebelli), 3 roots (mesiobuccal, distobuccal and
palatal)
• Mandibular molars: 5 cusps (3 cusps along the Buccal surface: mesiobuccal, distobuccal
and distal or mesiobuccal, midbuccal and distobuccal cusps) , 2 roots (mesial and distal)
HUMAN DENTITION
Humans have diphyodont dentition (having two sets of teeth, a primary and a permanent set)
Primary dentition Lower Jaw Upper Jaw Permanent dentition Lower Jaw Upper Jaw
Central incisor 6 months 7½ months Central incisor 6-7 Yrs 7-8 yrs
Lateral incisor 7 months 9 months First molar 6 yrs 6 yrs
First molar 10 – 12 months 14 months Lateral incisor 7-8 yrs 8-9 yrs
Canine 16 months 18 months Canine 9-10 yrs 11-12 yrs
Second Molar 20 months 24 months (After PM2)
First Premolar 10-12 yrs 10-11 yrs
Second Premolar 11-12 yrs 10-12 yrs
Second Molar 12 yrs 12 yrs
Third molar 17-23 years
(Wisdom tooth)
Dentine
• Mesodermal in origin
• Developmentally, cells responsible for dentine
formation, odontoblasts differentiate as single
layer of tall columnar cells on the surface of dental
papilla (pulp) apposing amenoblast layers.
• After tooth formation is complete, a small amount
of less organized secondary dentine continues to
be laid down-progressive obliteration of pulp
cavity with increased age (in kids pulp cavity is
large)
• Composed of calcified organic matrix similar to
that of bone: glycolsaminoglycans with numerous
collagen fibers.
• Inorganic component constitutes larger proportion
of matrix and dentine than that of bone and exists
mainly in the form of calcium hydroxyl apatite
crystals.
• Softer (70% inorganic material) and elastic in comparison with enamel (96%) but harder than bone (45%).
• Dentine forms the main body of teeth.
• Extends from crown to root and is yellow in color.
• From pulp cavity minute papillary tubules called dentine tubules radiate ( odontoblastic processes) to the
periphery of dentine.
• If dentine is exposed by any means: sensitivity felt d/t hyperemic condition at the pulp. The pain
disappears as soon as sensation is removed.
• Sensation in dentine is due to odontoblastic processes and nerve endings.
Enamel:
• Ectodermal in origin.
• Highly mineralized, yet developmentally develops from cellular structures in the form of ameloblast
(Ectodermal in origin) but ameloblasts die during eruption.
• It is acellular, avascular and aneural and is hence a dead tissue (can't be repaired- increases force during
chewing)
• Made up of 96% pure inorganic material calcium hydroxyapatite crystals (Ca phosphate, Ca carbonate)
• Outermost covering and protective layer of crown
• Color: Grayish white to yellowish white : depends on thickness of dentine which is yellow.
• Thinnest at cervical line and thickest at the cusps.
• Loss of enamel:
o Leads to exposed dentine.
o On taking hot/cold substance – sensation taken by odontoblastic recesses. Nerve endings to pulp-
brain-reacts and causes hyperemia-increased blood flow -increases pressure-nerves compressed –
mild pain k/a sensitivity.
o Alright after avoiding stimulus.
• No dentine: F.B reaches pulp tissue: pulp reacts by full-fledged inflammation: hyperemia, exudation,
swelling, severe pain (throbbing).
Dental pulp
• Mesodermal in origin
• Highly vascular delicate connective tissue derived from dental papilla.
• Contained within pulp cavity which includes:
o Pulp chamber in crown: contains coronal pulp
PERIODONTIUM
It consists of:
1. Supporting tissues (Attachment apparatus):
a. Alveolar Bone Alveolar bone
b. Cementum Periodontal
c. Periodontal Ligament ligament
2. Investing tissue:
Cementum
a. Gingiva or Gum
Gingiva
• Surrounds alveolar bone, periodontal ligament and cementum (attachment tissues)
• It is epithelial tissue, coral pink in color, with orange peel appearance (stippling is normal), should not
bleed.
• Investing layer which gives protection to all attachment tissues.
• Parts:
o Marginal(free) gingiva
o Attached gingiva
o Alveolar mucosa
o Interdental gingiva(papilla)
• Free gingiva forms a cuff around the enamel at the neck of
tooth.
• Free gingiva is margin of gingiva which is not attached to
underlying bone, tooth structures.
• Tip of free gingiva: thin layer of epithelial cells
• Only 2 or 3 cells thick as the base of gingival crevice
• The sulcal or crevivular epithelium is easily breached by
pathogenic organisms and the underlying supporting tissues are
thus frequently infiltrated by lymphoid cells.
• Between enamel and free gingiva is a potential space called
gingival sulcus which is normally 0.5-1.5mm in size up to 3mm deep, and has non-keratinizing epithelium.
o If depth >3mm it is called a pocket and is pathological: measured by periodontal probe: graduated
in mm.
• Attached part provides a protective covering to upper alveolar bone, is firm, not mobile and keratinized.
• Oral aspect of gingiva: stratified squamous epithelium
Cementum
• Mesodermal in origin
• Covering layer of root
• Light yellow in color and avascular
• Anchors to jaw bone by fibrous connective tissue
• Periodontal membrane is regarded as periosteum of cement
Alveolar Bone
• Alveolar arch
• Interdental septum
• Intra radicular bone
Periodontal Ligament
• Functions
o Support
o Shock absorber
o Propriocpetion
o Formative
o Nutrtion
1 | 2 5 | 6
R--------------------L R--------------------L
4 | 3 8 | 7
87654321|12345678 54321|12345
R --------------------------------------- --------------L R ------------------------------- ----L
87654321|12345678 54321|12345
• Thus, the left maxillary wisdom tooth, is denoted by “28” and read as “two-eight”; similarly the right
nd
mandibular 2 molar is denoted by “85” and read as “eight-five”
• Thus, the permanent dentition will have the following notation:
METHODS OF CLEANING
1. Mechanical cleaning:
• Brushing with a tooth brush
• Dental floss
• Massage to gum
• Wood pecks
2. Chemical cleaning
• Chlorhexidine
3. Change of diet:
• Low sugar content
4. Scaling:
• Manual (conventional scaling)
• Ultrasonic
BRUSHING TECHNIQUE:
• Different techniques:
1. Vertical
2. Horizontal
3. Vibratory
4. Roll’s method (sweep method)
5. Bass method (sulcular method)
6. Modified Bass method
7. Charter’s method
8. Modified Stillman’s method: Recommended for cleaning areas with progressing gingival recession
and root exposure to minimize abrasive tissue destruction
9. Fones method: Recommended for young child who wants to brush themselves
10. Scrub method: Vigrous horizontal, vertical and circular motions. Ineffective and leads to tooth
abrasion and gingival recession
• Roll’s technique (sweep):
o Especially for Interdental area
o Side of brush is placed against the buccal aspect of teeth and gingiva
o Back of brush should be at the level of biting surface
o Bristles are parallel to long axis of teeth
o Rotate the brush: downward in upper jaw and upwards in lower jaw
o Side of brush cleans (sweeps) tooth and gingiva and bristles are forced into an Interdental area.
o Strokes are given for each of 6 segments in one half of each jaw
o 5-10 strokes each for buccal and lingual aspect of each tooth
o Lingual and palatal aspects of ANT segment are swept vertically by the width of brush and rotary
movements for occluded surfaces
• Bass technique
o Aka crevicular or sulcular technique
o Imp for cleaning gingival sulcus
0
o Brush kept at 45 to long axis of teeth with bristle ends pointing into gingival sulcus across the
gingival margin.
o Brush is then pressed slightly towards gingiva to enter the sulci making vibratory or circular
movements
• Modified bass technique
o Roll and bass technique both combined
• Gingival sulcus is important especially in old age.
EFFECTIVENESS OF TECHNIQUE
• Any technique is effective only if it can completely remove the plaque
• Effectiveness of plaque removal is assessed by disclosing solution or tablet which contains erythrosine
which is a non-toxic dye and stains plaque purple or pink
• The tablet is to be chewed and/or rinsed with solution
• Especially effective in children
• Procedure:
o Use after children have brushed
o Rinse with solution
o See in mirror
o If plaque is present, brush with modified bass technique to remove plaque: if not removed go to
dentist
BRUSHING FREQUENCY
There are certain factors which determine the frequency of brushing:
• It takes 8 hours for dental plaque to mature
• 4 S: soft, sugary or sweet, sticky and stuck
Considering all these factors, at least once a day brushing before going to bed: must and each time after taking
soft, sugary, sticky and stuck food.
• Food particles accumulate especially in space between free gingiva and tooth called sulcus
• Technique that reaches this sulcus is called sulcal
• Technique not reaching this sulcus is called non-sulcal
• If the teeth and gingiva are healthy on examination, the technique used is correct, then vice versa
• Teach accordingly, if the person is a child, mentally sound or subnormal
• Scrub technique: to and fro movement of brush on the surface of tooth
o Long scrub
o Short scrub
• Short scrub technique applied on molars and premolars for occlusal surface
• Vibratory technique : tip of bristle fixed
o
• To clean sulcus, either vibratory or circular vibratory technique applied every 6-8 times with brush at 45
angle to longitudinal axis of tooth
• Clean teeth in sequence so that no segment is missed
• Do not damage gingiva by hard bristles or more by force (so hold brush far from head of brush)
• In elderly: bristles parallel to buccal/palatal surface
• Electrical brush available for physically or mentally handicapped but is expensive
INTERDENTAL CLEANING
• The interdental area is an important site of plaque collection and is inaccessible to tooth brush. Following
methods can supplement normal brushing:
o Dental wood stick
Irregular in cross section and tapering
Interdental space ,must be present
Teeth must be clean and gingiva must be totally healthy for it to be used
Used at an angle following gingival contour to avoid trauma to gingiva
If used straightly, Interdental papillae will atrophy
o Interspace brush: One bristles or little baby bottle brush used for irregular teeth, missing teeth,
erosion
o Dental floss
A thread that is waxed or unwaxed
Remove plaque, food debris from Interdental spaces.
Used daily
18 inches long
DENTRIFICE
• Any liquid, paste or powder used to clean teeth
• Most commonly used: tooth paste
• Functions of tooth paste:
o Detergent: helps in removal of dental plaque chemically
o Refreshes breath
• Tooth powder is abrasive and removes plaque mechanically by abrasion
SCALING
• Removes both supra and sub gingival calculi
FORMATION:
• The process of plaque formation can be divided into 3 stages:
1. Formation of dental pellicle:
o Hydroxyapatite of enamel has an affinity for glycoprotein so that a thin adhesive layer is
formed on the surface of tooth called glycoprotein pellicle
o Glycoprotein pellicle is derived from :
Saliva
Crevicular fluid
Bacterial and host tissue cell products
Food debris
2. Initial colonization by bacteria
o Occurs within 6-12 hours
o The initial colonizers - aerobic gram positive facultative microorganisms e.g. Actinomyces
viscosus, Streptococcus sanguis.
3. Secondary colonization and plaque maturation
o Secondary colonizers - anaerobic gram negative bacteria. e.g. Prevotella intermedia, P.
loescheii, Capnocytophaga species, Fusobacterium nucleatum, Porphyromonas gingivalis.
o Co-aggregation
o After 48 hours, virtually the whole layer is covered by bacteria
o The plaque now becomes very much adherent t o the tooth surface and can’t be removed by
water rinsing or hand pressing (5-10 strong mechanical brushing strokes required)
• Growth of the plaque:
o Adhesion of new bacteria/organism
o Multiplication of existing bacteria
o Accumulation of metabolic products of bacteria (fermented products of proteolysis)
o Protein, carbohydrate from food debris
Starts within 6hrs of thorough brushing
In 24hrs, majority of plaque can be detected
Supra-gingival
• Sites: The plaque is formed everywhere especially on hard surfaces
o Supra-gingiva
Sub-gingival
o Sub-gingival (in the gingival sulcus)
o Gingival Gingival
COMPOSITION :
The plaque is composed of:
o 70-90% microorganism
o 10-30% organic and inorganic materials including interbacterial matrix (~10%)
Microorganisms
Bacteria: • Gram negative cocci (facultative)
• Gram positive cocci o Neisseria gonorrhea, meningitides
o Strep mutans, viridians, milliri, mitis o Morexella cattarhalis
o Staph aureus, albus, pyogenes • Gram negative bacill (facultative)
(facultative) o Actinobacillus Actinomycetemcomitans
o Pneumococcus (facultative) o Campylobacter rectus
• Gram positive bacilli o Eikenella corrodens
o Lactobacillis acidophilus o Enteric rods
o Odentophytic, fermenti. o Pseudomonas
PREVENTION OF PLAQUE
• Mechanical method
o Thorough brushing and suitable dentifrice
o Dental floss
o Interdental brush
o Dental wood stick
o Gingival massage
• Chemical method
o Chlorhexidine gluconate: 0.1-0.2%
o Providone-Iodine (1-2%)
o H2O2 3%
o Benzyl amine 0.15. %
• Food habits
o Avoid or restrict intake of 3S
o Encourage fibrous foods, soybean, grains, and vegetables. And fresh fruits and vegetables
• Treatment
o Tooth brushing
o Scaling
FORMATION:
• Acquired pellicle dental plaque mineralization dental calculus
• Can form anywhere but is maximum over:
o Lingual surface of lower teeth.
o Buccal surface of upper teeth.
• Many calculi are formed at the opening of salivary gland ducts:
2+
o Duct opening: availability of Ca in salivary secretion.
COMPOSITION :
• Inorganic (70-90%) CaCo3, Ca(PO4)2, MgCo2, Mg3(PO4)2, CaSO4, fluorides
• Organic (10-30%) Bacteria (Streptococci, Staphylococci) , Candida, Desquamated epithelial cells, Dead
WBCs, Protein, Carbohydrate.
PREVENTION
• Prevent formation of plaque (Plaque can change into calculus in 15-20 days) and scaling.
COMPLICATIONS
• Gingivitis and Aesthetic problems.
ETIOPATHOGENESIS
• Demineralization and remineralization:
1. Demineralization and remineralization is a dynamic process
2. The rate of demineralization is
inversely proportional to the
degree of saturation of calcium,
phosphate and fluoride ions in
the saliva, and the pH of the
solution
3. In the early stages, the tooth
surface remains intact and
demineralization is reversible but once the tooth surface collapses to expose a cavity, the process
cannot be reversed
4. Remineralization occurs when the pH increases and calcium and phosphate from saliva together with
fluoride form new hydroxyapatite crystals on the enamel surface and the body of the lesion
• Many theories regarding mechanism of evolution of caries.
1. Acidogenic theory: (in exam write about demineralization & remineralization, Stephan’s curve and
cariogenic bacteria as well)
• Widely accepted
• According to this theory, dental decay is a chemico-parasitic process consisting of 2 stages
i. Demineralization of enamel and its destruction
ii. Demineralization of dentine with dissolution of softened residue: acid affecting
dissolution is obtained from starch and sugar fermentation by microorganisms which
are mostly acidogenic
• Dental plaque helps acid to stay in contact
• Stephan’s curve shows the changes in pH in relation with the food (critical pH is 5.5)
2. Proteolytic theory
• In addition to acid production, plaque bacteria produce Proteolytic enzymes that destroys
organic portion of tooth making it easier for microorganisms to invade enamel and dentine
The Stephan’s curve describes the pH change in relation to the food intake (Critical pH for caries formation is
5.5). The second figure shows the Stephan’s curve according to different salivary flow rate.
1. Stephan Curves describe the changes in pH occurring within dental plaque when it is subjected to a
challenge, typically with a foodstuff
2. When challenged with a fermentable carbohydrate the pH within plaque drops rapidly and then rises back
to the resting pH more slowly
3. Factors affecting the shape of the Stephan Curve include the microbial composition of the plaque; the
nature of the fermentable substance; the rate of diffusion of bacterial metabolites, salivary components
such as bicarbonate and the fermentable substance; salivary access to the plaque; saliva flow rate
4. Saliva exerts two effects. First, it dilutes and carries away metabolites diffusing out of the plaque. Second it
supplies bicrabonate ions which diffuse into plaque and neutralise the by-products of fermentation
(organic acids) in situ.
5. The relationship of the shape of the Stephan Curve to the Critical pH can be used to assess the relative
cariogenicity of foods
C ARIOGENIC BACTERIA:
• Streptococcus mutans ( most potent) and S. sobrinu because of:
o Its ability to produce aid by sugar fermentation
o Its ability to polymerize sugar (esp. sucrose) into polysaccharides like polyglyans or dextrans which
helps:
Dental plaque to adhere to tooth
Bacteria to adhere to tooth
• Streptococcus viridians, streptococcus salivarics, Streptococcus mitis, Strep sanguislactobacilli
• Main acids produced are:
o Lactic acid
o Acetic acid
M ANAGEMENT
• Principles of Management Of Caries:
o Removal of decayed enamel and dentine
o Removal of adjacent stagnation surfaces e.g. pits and fissures
o Protection of pulp (by putting an insulation lining to prevent sensitivity with a metallic filling like
ZnSO4 or by indirect pulp capping)
o Maintenance of water tight restoration
o Restoration of original shape and form of tooth
• Enamel and dentinal caries restoration
• Pulpitis, periapical periodontitis root canal treatment
• Periapical granuloma, periapical cyst enucleation/marsupialization
• Cellulitis, osteomyelitis, cavernous sinus thrombosis specific management
PREVENTION OF C ARIES
Complete removal of plaque
• Brushing
• Scaling
Modifying plaque
• Addition of Na, Ca phosphate to Cariogenic diet decreases caries in animals
• Intraoral
o Intraoral Periapical (IOPA): Visualization of crown, root, periodontium, periapical region,
alveolar bones
o Occlusional radiograph: for sialolithiasis
o Bite wing:
Visualization of crown of upper and lower teeth
For diagnosis of proximal or incipient caries
• Extraoral
o Orthopantamogram (OPG): a screening radiograph showing teeth, jaw and TMJ
o Lateral cephalogram: growth-study and orthodontics
o PNS view/Water’s view for PNS
o Submento vertex view: for zygomatic process
o PA skull
o Transpharyngeal view for TMJ
o Towne’s view and reverse Towne’s view
o PA and lateral mandible
o Lateral oblique view
• CT and MRI are generally reserved for complex maxillofacial surgeries involving cysts, trauma,
cancers, etc.
C AUSES:
• Local factors:
o Insufficient and inefficient tooth brushing
o Stagnation of soft, sticky food, imbricated teeth (crowded teeth)
o Badly restored teeth: rough surface, irritated gingiva
o Prosthesis, orthodontic appliances: irritable margin: food gets collected
o Mouth breathers and incomplete lip seal (dry: inflammation)
o Bacterial and viral infection
o Trauma (traumatic bites, tooth, fishbone, brush., fingernail )
• Systemic factors:
o Vitamin C deficiency: scurvy
o Vitamin B complex deficiency
B2: glossitis, stomatitis, gingivitis.
B3: pellagra: 3’D’ and gingivitis
o Hormonal imbalance
Puberty: increased estrogen
Pregnancy: increased progesterone
o Drug induced
Phenytoin, cyclosporine, nifedipine, OCP cause gingival hyperplasia
o Diseases: DM, TB, anemia, nephritis
o Allergy to dentifrices, mouthwash
TYPES
• Acute gingivitis
• Chronic gingivitis
ACUTE GINGIVITIS
1. Acute Necrotizing Ulcerative Gingivitis (ANUG)
2. Herpetic gingivitis
3. Non-specific or streptococcal gingivitis
4. Leukemic gingivitis
HERPETIC GINGIVOSTOMATITIS
• Due to Herpes Simplex Virus and Herpes Labialis Virus.
• Children are prime victims
• Clinical Features
o no necrosis
o Interdental papilla not involved
o at first small vesicles are formed, later they join together to from big ulcer
o site of ulcer-gingiva, tongue, lips, cheek and palate
o typical grayish ulcer with red margin
o general: sudden onset fever, malaise, photophobia, irritability
• Management
o Heals spontaneously within 7-14 days if no secondary bacterial infection
o 3% H2O2 mouth wash
o 250 mg tetracycline capsule dissolved in 30 ml H2o and wash 3-4 times a day for the prevention of
secondary bacterial infection
o Acyclovir and idoxyuridine for one week can be given
o Bes rest
o Soft food, plenty of fluid
o Mild analgesics
LEUKEMIC GINGIVITIS
• Painful, swelling of gum and spontaneous bleeding
• Anemia and lymphadenopathy
CHRONIC GINGIVITIS
• Causes
o Persistence of low grade inflammation due to presence of plaque, calculus
o Incompetent lips: mouth breathing
o Prosthesis and orthodontic appliances
o Traumatic bites
o If lower teeth continuously strikes palatal region of upper teeth
o If acute gingivitis not treated
• Clinical Features
o Cardinal Features
Color change: red to purple
Loss of stippling: becomes glossy
Swelling due to inflammation
Bleeding: on probing or spontaneous
o Other: soft, spongy, gingiva may be detached from the neck of teeth, either it can recede
downwards apically (gingival recession or apical migration) or grow coronally (coronal migration)
to form pockets
o Pain is the most common complaint with acute gingivitis but there is no pain in chronic gingivitis:
so progresses to irreversible periodontitis
• Management and treatment plan:
o Prevention of plaque calculus
o Maintain good oral hygiene
o Eliminate or treat the cause
o Treat accordingly to type of disease
ACUTE PERIODONTITIS
• Less common than the chronic form
• Causes
o Injury
Sudden blow, fall, trauma
Sudden bite on hard object, high fillings
o Infections:
Pulpitis
Pulp necrosis
Caries
o Irritation: overfilled root canal which irritates the periodontal membrane
o Impaction of FB:
o Needles, bone, etc.
o Infection is usually because of Staphylococcus, Streptococcus, Borrelia, and Fusiform bacilli
• Clinical Features
o Pain
o Feeling that tooth is extruded or elongated so that he cannot bite together due to inflammation
and exudation
o Fever, malaise
o Regional lymph nodes may be enlarged and tender
o ANUG or Vincent’s angina: rapidly progressive and destructive diseases of periodontal tissue
o Tenderness of percussion horizontal percussion is positive (vertical percussion positive with
periapical lesions like periapical abscess or pulpitis)
• Treatment:
o Removal of cause
o Advise not to chew from affected side
o Hot saline mouthwash
o Soft food
o Anti-inflammatory, or analgesics
o If infected: antibiotics(usually relived in a few days)
o RCT in anterior teeth if possible in selected cases
o If infection or inflammation become more severe: pain intensifies and becomes throbbing and if
periapical abscess starts to develop , treatment is drainage
CHRONIC PERIODONTITIS
• Common type of periodontal diseases and is the main cause of teeth loss in adults
• If ignored it leads to deepening of physiologic sulcus and destruction of periodontal ligament
• Pockets develop and teeth become filled with pus and debris
• As periodontium is destroyed teeth loosen and exfoliate
• Eventually there is resorption of alveolar bone
• Causes
o Untreated chronic gingivitis
o Occlusal trauma
o Excessive force applied during orthodontic treatment
• Main Pathological Features Are:
o Destruction of periodontal membrane
o Resorption of alveolar bone
o Formation of periodontal pockets (3-6mm): slight 3-4 mm, moderate 4-6 mm, severe ≥6 mm
o Loosening of teeth
o Periodontal tissue can bear 100 pound weight equivalent to biting
TREATMENT
• I and D of abscess through pulp or periodontal approach
• Drainage should be kept open if not properly drained
• Antibiotics
• Analgesics
• Hot saline water mouth wash
• Immediate extraction especially in periapical periodontitis
C AUSES
• Impaction: food collection, stagnation inside the flap or operculum, provides favorable media for bacterial
growth and inflammation.
• Injury: if upper tooth is continuously traumatizing lower gum flap.
• Vincent’s infection: can start from pericoronal pocket or spread to pericoronal pocket from other sites of
gingiva
• Decreased resistance to infection e.g. common cold, Diabetes Mellitus, Anemia , TB
• Eruptive irritation:
o Bouts of pain or attack of pain occurs in between every 2-3 yrs
o After that for a few months or years: silent period: no pain
o But in eruptive phase pain appears
CLINICAL FEATURES
• Soreness and tenderness followed by pain and swelling
• Due to inflammation there is spasm of muscles of mastication
o Trismus: difficulty in opening mouth
• Dyshagia
• Systemic: fever, malaise, halitosis due to inflammation
• Regional lymphadenopathy
• Abscess formation in extra or intraoral region (pericoronal abscess)
rd
• Pterygomandibular space infection in impacted 3 molar and pericoronitis
M ANAGEMENT
• Manage acute condition and definitive treatment
Acute condition
• Clean all area with H2O2 or Normal Saline (irrigation)
• Antiseptic solution: Chlorhexidine gluconate, etc.
• Hot salt water mouth wash 2-3 times daily
• Analgesics and anti-inflammatory
• Antibiotics started ASAP
o Penicillin-amoxicillin (80% effective)
o Metronidazole (25%)
o Or both together
o Soft food
o Oral hygiene
Definitive management
1. Conservative management: (continuation of antibiotics and maintenance of oral hygiene)
o Indications:
Adequate space available for tooth to erupt
Angulation is favorable
Teeth has good occlusion with antagonist teeth: Advice for intra oral periapical X ray and
OPG (oralpanoramogram) if not inline: extraction is advised
2. Operculectomy: Surgical removal of pericoronal flap
3. Tooth extraction:
o Indications:
Recurrent pericoronitis
Teeth doesn’t have good occlusion with antagonist teeth
4. Removal of upper teeth if pain
ETIOLOGY :
• Dental caries: extending up to pul p (most common cause)
• Traumatic:
o Attrision, Abrasion or Erosion leading to pulp irritation
o Fracture of crown
• Cracked tooth: Splitting of tooth which usually occurs in Pre Molar due to masticatory stress
• Thermal effect (Iatrogenic)
o E.g.: heat production during drilling especially when done without using water: over rapid cavity
penetration: also in silver filling
o To prevent thermal effect, underneath filling Zn(PO4) is used as insulator
• Nonspecific infection: Due to streptococcus, other organisms via deep caries or via hematogenous route
(bacterial invasion) Anachoresis and this pulpitis is called anachoretic pulpitis
• Chemical injury: Cements (silicate), mercury alum
P ATHOGENESIS:
• Sequence of events leading to pulpitis:
o Dental caries -> Cavitation of enamel -> Penetration of tooth pulp -> Pulpitis
• Infection localized to pulp chamber (crown) and pulp cavity (root) which are closed, fixed and rigid space ->
accumulation of exudates in pulp space -> increased pressure (limitation for apical foramen) -> increased
circulation -> impaired venous return and impaired arterial supply -> pulp necrosis.
• If treated in early stage: reversible and localized tooth becomes sensitive to percussion and hot or cold
and pain resolves immediately when irritating stimulus is removed
• Late stage: irreversible pain is severe and is sharp or throbbing worsening on lying down
• If infection spreads throughout the pulp: irreversible pulpitis occurs: pulp necrosis.
• Once pulp necrosis is complete, pain may be constant or intermittent but cold sensitivity is lost
(differentiates irreversible from reversible pulpitis)
• Pulpitis is a nonspecific infection because multiple bacteria are involved: streptococcus and other bacteria
present in carious cavity are mostly responsible
TYPES OF PULPITIS:
• On the basis of duration of onset:
o Acute: rapid, onset, sever and of short duration
o Chronic: slow development, long duration
• On the basis of communication with external environment:
o Open (Pulpitis aparta) : pulp cavity and oral cavity communicate
o Closed (Pulpitis clausa): no such communication exists
• On the basis of involvement:
o Partial
o Total
• On the basis of bacterial environment:
o Sterile
o Infected
• Grossman’s clinical classification of pulpitides (plural of pulpitis)
1. Reversible pulpitis (chronic caries, cutting dentine during cavity preparation, thermal insulation,
acid etching, sever attrition or abrasion of tooth)- No pain without stimulus (hot or cold)
2. Irreversible pulpitis – Pain even without stimulus
i. Acute
ii. Chronic
a. Asymptomatic with pulp exposure
M ANAGEMENT OF PULPITIS
• Pulp capping:
o In very deep caries without exposure of pulp cavity, indirect pulp capping (IPC) is done
o In recently exposed pulp cavity with opening <1mm without any infection or pain: pulp capping is
done (direct pulp capping or DPC) Ca(OH)2 applied at exposed parts
o If pulp cavity opening >1mm: needs extirpation and RCT.
• Pulpotomy
o Partial removal of pulp
o Coronal pulp is amputated leaving the remaining radicular pulp to heal
o Pulpotomy is an intermediate treatment modality when apex is wide ( e.g. in children with
incomplete development) and RCT is not possible
o Newly exposed pulp cavity is treated with pulpotomy instead of RCT which is done later if pulp
dies
• Root canal treatment (RCT) is the ultimate solution for all types of pulpitis in which there is no indication
for teeth extraction
• Extraction: effective but destructive way of treating pulpits
o Not always treatment of choice, however it is undertaken when patient cannot afford RCT
o In severe pulpitis, LA may not work
o However it is safe in that there are no complications like spread of infection
COMPLICATIONS OF PULPITIS
• If pulp infection doesn’t decrease: periapical abscess formation (pain on chewing)
• If mild and chronic infection: periapical granuloma or eventually periapical cyst which produces
radiolucency at root apex
• When untreated a periapical abscess can erode into the alveolar bone producing osteomyelitis, penetrate
and drain through the gingiva (parvis or gumboil) or track along deep fascial planes producing a virulent
cellulits (Ludwig’s Angina) involving submandibular space and floor of mouth
• Elderly patient with DM and pt taking glucocorticoids may experience little or no pain and fever as these
complications develop.
Class I occlusion The mesiobuccal cusp of the upper M1 fits with the buccal groove of lower M1
Class II occlusion The mesiobuccal cusp of the upper M1 behind the buccal groove of lower M1
Class III occlusion The mesiobuccal cusp of the upper M1 in front of the buccal groove of lower M1
M ALOCCLUSION
• Increased overjet, Increased overbite
• Class III or class II occlusion
• Requires orthodontic treatment: braces
TREATMENT
• Photography
• Dental caries prepared
• Separators placed and Braces Kept
ATTRITION
• Definition: ‘The physiological wearing away of the tooth surface
as a result of tooth to tooth contact’ as in mastication
• Causes:
o Coarse gritty diet
o Nervous habit (grinding teeth in anxiety)
o If at night, known as bruxism
o Chewing pipe
o Marked malalignment or malocclusion
o Loss of posterior teeth
• Sites
o Anterior: incisor edges
o Posterior: occlusal surface of teeth
• Affected sites appear smooth and polished but in advanced attrition, incisor edges and cusps are worn
away and become peg like, occlusal surface becomes flat and even hollows out
• Attrition is a slow process so even in advanced cases pulp may not be exposed due to dentine formation
• The dentine may be exposed and stained
• Attrition is not compatible with caries and periodontal problems because the latter two leads to
destruction and mobility of teeth because of which attrition does not occur
• Attrition helps in preventing caries by destroying stagnation areas of occlusal surface
ABRASION
• Definition: ‘The abnormal wearing away of tooth tissue by a mechanical process’
• Causes: chewing tobacco, vigorous tooth brushing using tooth powered, certain professions like cutting
thread, etc.
• Hard tooth brushing with horizontal sweeping action is the
commonest cause of abrasion
• Site: neck of teeth near cervical margin usually after gingival
recession (because cememtoenamel junction is the most susceptible
to abrasion)
• A major degree of gingival recession is also seen but no gingivitis
occurs due to effective plaque removal
• Corner teeth are the most severely affected
• First cementum and then dentine are exposed: groove is found
• Appearances:
o Worn ‘notches’ on the incisal surfaces of the anterior teeth
o Worn, shiny often yellow/brown areas at the cervical margin
EROSION
• Definition: The loss of tooth tissue by a chemical process that does not involve bacteria
• It is progressive dissolution of tooth usually by acid solution but sometimes due to
unknown causes (non-carious pathological loss of teeth tissue)
• Causes
o Extrinsic:
Occupational: common among workers of battery/acid factories due
to exposure to acid fumes
Habitual sucking of citrus fruits for long duration
Soft drinks have high H3PO4. Excessive intake of carbonated drinks:
developmental caries
o Intrinsic:
Chronic regurgitation of acidic gastric juice e.g. in APD, GERD, 1st trimester of
pregnancies. erodes especially the palatal surface of teeth
Excessive vomiting
o Erosion of unknown caries: shallow, highly polished in labial surface
ABFRACTION
• Definition: ‘The pathological loss of enamel and dentine due to occlusal stresses’
• Occlusal forces which cause the tooth to flex, cause small enamel flecks to break off,
inducing the abrasive lesions
• Usually wedge shaped lesions with sharp angles found at the cervical margins
SECONDARY DENTINE
• Secondary dentin is formed in response to a normal or slightly abnormal stimulus after complete formation
of the tooth.
• Secondary dentin is less mineralized.
• 6-10% less mineral than primary dentin.
• Types:
o Physiologic secondary Dentin
Laid down throughout the life of the tooth
Produced slowly
o Repairative secondary Dentin
Formed as a result of irritaion or attrition
DENTINAL SCLEROSIS
• Calcification of dentinal tubules
• Decreases the conductivity of the odontoblastic processes.
• Causes
o Normal ageing process
o Injury to dentin by caries or abrasion
PULP CALCIFICATION
• Calcification within the pulpal tissue
• Chief morphological forms
• Discrete pulp stones (denticles)
o True denticles: resembling dentin
o False denticles: not resembling dentin
• Diffuse calcification
• Causes
o Increased incidence with age
o Exact cause not known
• Clinical significance
o Sometimes painful
o Otherwise no significance
RESORPTION
• External resorption
o Periapical inflammation
o Reimplantation of teeth
o Tumors and cysts
o Excessive mechanical or occlusal forces
o Impaction
o Idiopathic
• Internal resorption
o Idiopathic
Internal resorption
in x-ray
Periapical inflammation
Impacted teeth
C AUSES
• Acute dislocation
o Yawning with excessive wide open mouth
o Biting hard substances with high pressure
o Traumatic fracture
• Chronic dislocation
o Idiopathic
o Laxation of muscles and ligaments
o Atrophic changes of muscles and ligaments
o Osterpanthroapthy
CLINICAL FEATURES
• Acute dislocation
o Aim
o Open mouth
o Pt is panicky
o Painful closure of mouth
• Chronic dislocation
o Painless or mild pain
o Open mouth
M ANAGEMENT
• Acute dislocation:
o Relaxing the patient
o Counseling the patient
o Analgesics
o Diazepam( to relax the muscles)
o Gauze piece over the last molar tooth: apply pressure first downward and then backward and
upwards usually the joint will reduce
o If above procedure fails try the same again under GA
• Chronic dislocation
o Results of management are not good and recurrence occurs very often
o Some maneuver or in a cute TMJ dislocation
o Teach the patient how to reduce
o Advice to avoid wide yawning
2. Pterygopalataine nerve
• Orbital branch- supplies periosteum of orbit
Dental Notes by Sadichhya & Shooga 38
ANESTHETIZATION
• To block pain during dental procedures
• Can be done by two methods
o Infiltration: Anesthetization of small terminal nerve ending in the area. Wait for three minutes
after injection, preferred technique as small area anesthetized.
o Block: Anesthetization of larger terminal branch (field block) or main nerve trunk (nerve block).
Wait for 5 minutes, done if infiltration is not possible or susceptible. Large area or unwanted areas
maybe anesthetized.
• Infiltration onto sub mucus layer: local anesthetic has to pass through cortical plate right up to pulp, so
cortical plates must have enough pores.
Methods of anesthetization: From above downwards, a) infiltration, b) field block, and c) nerve block
• Infraorbital N block
o To anesthetize both anterior and middle sup alveolar nerve, when multiple anterior teeth and/or
premolars are to be dealth with, thereby avoiding the need for multiple injection
o Infraorbital foramen is palpated from outside just below the inferior orbital border but needle is
inserted by about 1.6 cm through labial sulcus at the apex of PM1 and LA is injected.
• Post sup alveolar N block
o Used sometimes to anesthetize the premolar and molar together
0
o Needle inserted by about 1.6 cm at 45 to maxillary buccal sulcus above the M2 to pass above and
behind maxillary tubercle.
INDICATIONS
• Any tooth not useful for proper function should considered for extraction
• Periodontics/Endodontics:
o Gross carries of tooth which cannot be restored.
o Acute/Chronic pulpitis where RCT is not possible.
o Periodontal disease where bone loss is more than half of normal alveolar bone.
• Traumatic tooth injuries:
o If coronal half of root is fractured.
o If longitudinal fracture of tooth
o In case of jaw fracture. If tooth lies in fracture line.
• Orthodontics/prosthodontics indications:
o For aesthetic purposes (if protruding teeth, especially upper.)
o Prosthetic consideration where teeth are interfering with fitting or designing of denture.
o In orthodontic cases where arch is small or teeth are crowded (extractions are done to make
space for correction.
o Malposition or impacted teeth (which makes dental arch crowded and cause carries and damage
to adjacent teeth.
o Supernumerary teeth causing overcrowding or eruption disturbance.
o Retain deciduous teeth ( Permanent successor present)
o If tooth is hurting soft tissue
• Miscellaneous:
o In case of bone lesions where tooth is involved. E.g.: Cysts, tumors, osteomyelitis.
o Preparation of oral cavity for radio therapy, in case of oral cancer.
CONTRAINDICATIONS
General Contraindications
Local Contraindications
Absolute Contraindications
1. Hemangioma
2. AV malformation ( because bleeding that cannot be stopped)
(If such condition occurs put teeth on socket and press)
PROCEDURE
1. Give Local Anesthesia
2. After sensation is obtunded extract tooth by mobilizing root and extracting with forceps
‘Do’s Don’ts
• Rest • Do not spit or rinse as far
• Take prescribed medicines as possible: Clot might get
• Soft, lukewarm or cold food: Causes vasoconstriction dislodged
• Cold compression with ice pack from outside: With pack from outside it • Do not take hot food or
decreases surgical edema drink for 24 hours.
• Warm saline mouthwash from next day for two to three days, two to • Do not take caffeine:
three times a day. Causes vasodilatation
• If any bleeding, pain, or complaint, contact hospital • Do not smoke or drink
COMPLICATIONS
• Dry socket (common complication of tooth extraction that can cause severe pain).
• Complications related to anesthesia:
o Failure to secure anesthesia
o Other complications of LA (@PANT)
o Prolonged pain
• Failure to extract
• Incomplete extraction: A portion of the tooth may be left in the jawbone, increasing the risk of infection.
However, there are some instances where a small root tip is intentionally left in the jaw because removing
it would be too risky (e.g., potential for damaging a major nerve).
• Traumatic extraction:
o Fracture of crown, alveolus, maxillary tuberosity, and mandible.
o Dislocation or damage of adjacent tooth or TMJ.
o Displacement of root into soft tissues or maxillary antrum i.e. sinus cavities
o Damage to gingiva, lips, inferior mental nerves and its branches, lingual nerve, tongue, palate.
• Postoperative or intraoperative hemorrhage and hematoma formation
• Orodental communication
• Allergy or systemic complications
• Infections
SOME FILLINGS
Restorative material Cements (Temporary)
1. Miracle mix ZOE (Zinc oxide eugenol)
•Silver and glass ionomer cement (GIC) Zinc phosphate
•Silver amalgam: hard but not sticky Zinc polycarboxylate
•GIC: Sticky but not hard Silicate
•Takes 2 hr to set, therefore do not allow to drink for 2 hrs, use waterproof Silicophosphate
cream to prevent from action of saliva
2. Silver amalgam filling
3. GIC filling
4. Composite filling: Light and strong and good color match
STEPS
1. Acid etch applied on surface of enamel
• 34% orthophosphonic acid
• Dematerializes surface of tooth creating pores
2. After few seconds, wash.
• There will be a dull chalky white discoloration
3. Bonding liquid (organic monomer) added
• Flows into the pores formed by etching and fills the pores
4. Composite material added over this
5. Light (intense blue visible light) passed
• Polymerizes organic monomer and sets the composite material
6. After filling patient is asked to bite so that any extra filling material is removed and material fits the shape
of teeth
TWO TYPES:
• Indirect pulp capping (IPC)
o When pulp cavity is not exposed IPC done
o Pulp cavity is covered with Ca(OH)2 (Dycal) and temporary filling with zinc phosphate
o If no symptoms for 6 weeks, then secondary dentine formation has taken place
o Remove the temporary filler and then replace with permanent filler
• Direct pulp capping (DPC)
o When pulp cavity already exposed, but exposure is less than 1mm and chance of infection is less.
o Pulp cavity is covered with Dycal and then temporary filling with Zn3(PO4)2.
o Dycal helps to regenerate secondary dentine, after 3 to 4 weeks thin layer of dentine develops
o Soft dentine is removed and filling is done on hard dentine
o But if there is a thin layer of dentine, which even if soft and removed causes exposure of pulp,
leave the soft dentine and line with Dycal because it helps to calcify.
o Fill with GIC temporary filling
PROCEDURE:
• Steps in procedure:
o Access pulp cavity by making hole or opening
o Biomechanical preparation: Extrication of dead pulp, cleaning repeatedly
o Working length estimation(radiological)
o Obturation (filling of root canal or pulp cavity)
Gutta-parcha is used for this purpose, and the opening is sealed initially with temporary
filling
If no pain after few weeks permanent filling is done
o Crowning
• While cleaning, steroid (septadont dexamethasone acetate), antiseptic, anti-inflammatory analgesic used
• Restorative material:
o Amalgam
o Composite
o Glass Ionomer Cement (GIC)
• Cements: These are used to make the base for filling the restorative materials
o ZOE (Zinc Oxide Eugenol)
o GIC
o Zn polycarboxylate
o Silicate
o Silicophosphate
o Zn phosphate, calcium hydroxide
CLINICAL FEATURES
• Pain (which is usually sever when patient moves the jaw)
• Swelling
• Deformity of face and especially of occlusion of teeth clicking
• Diplopia
• Abnormality of mobility: Difficulty in opening the mouth( inability to close the mouth)
• Anaesthetized of face and lip
AIMS OF M ANAGEMENT
• To restore the face (both aesthetically and functionally)
• To prevent complications (disfigurement, malocclusion and
diplopia) that result from improper management of facial injuries
STEPS OF M ANAGEMENT
• Airway maintenance
• Bleeding control and appropriate fluid resuscitation
• Pain management
• Infection management
• Repair of soft tissue injuries
• Evaluation for the presence of brain injury : observe for 24h
• Specific management:
• Maxillo-Mandibular Fixation (MMF) or Intermaxillary fixation (IMF): Operative reduction of
maxillary/mandibular fractures with placement of arch bars to the maxillary and mandibular dentition,
followed by restoration of the dentition to normal occlusion and then tying the two arch bars together with
interdental wire. This procedure is necessary to reestablish the proper dentoskeletal relationships,
immobilize the fractured bones, and ensure normal postoperative occlusion.
• In general, MMF should be completed prior t o reduction and fixation of other segments of the maxilla.
• In edentulous patients (patients without teeth), dentures or surgical (acrylic splints with circumzygomatic
and circummandibular fixation helps in restoring the occlusion (MMF will lead to gum ischemia and
necrosis in these patients).
ADVANTAGES DISADVANTAGES
• Inexpensive • Cannot obtain absolute stability
• Short procedure/limited operating time • No compliance from the patient due to long period of
• Generally easy, no great operative skill fixation
required • Loss of patient to follow up
• Biologically conservative, no need for • Difficult nutrition
surgical tissue damage • Complete maintenance of oral hygiene not possible
• No foreign body/material in the body • Problematic for patients with premorbid pulmonary
function, psychological disorders, seizures
• Issues in children:
o Fractures heal within short time, so early treatment within 1 week is necessary to prevent
malunion
o Permanent tooth buds are present along the roots of primary teeth, and these can be easily
destroyed by use of hardware
o The growth centres may get injured leading to asymmetrical growth
o Even immobilization of few weeks can causes TMJ to become fixed
CLASSIFICATION
CLINICAL FEATURES
• Swelling and ecchymosis
• Deformity in the bony contour of mandible
• Derangement of occlusion
• Unilateral/bilateral posterior gagging
• Anterior open bite
• Abnormal mandibular movement: unable to
open or unable to close
• Anesthesia/paresthesia of lower lip
• Loose teeth
R ADIOLOGICAL EVALUATION
• Paranomic view (unobstructed clear view), orthopantamogram (OPG) commonly done
• Towne’s view
• PA view and Lateral view of mandible
• CT scan
• Occlusal view of maxilla and mandible
• CM view of right and left side of mandible
Closed reduction (i.e. only MMF) Open reduction with rigid or non-rigid fixation
• Non-displaced angle fracture (tooth in proximal • Non-displaced vertically modified
segment) symphysis/body
• Ramus fracture • Displaced angle fractures
• Non-displaced symphysis fracture(mobile body) • Condylar occlusion
• Non or minimally displaced high condyle fracture • B/L severe condylar displacement with
• Intracapsular condyle fracture comminuted mid face fracture
OPEN REDUCTION
Internal fixation: After open reduction, this method is used either with or without MMF.
Non-rigid fixation Rigid fixation
(MMF should be continued after fixation) (MMF can be removed after fixation)
Circumferential wiring Bone plate (common):
• SUP border wire • Compressible
• INF border wire • Non-compressible
Transfixation with Kirschner wire or skeletal pins • Mini-plates
Lag screws
ADVANTAGES AND DISADVANTAGES OF OPEN REDUCTION WITHOUT MMF (i.e. with ri gid fixation)
• Because of early return of function and because of need for prolonged immobilization with MMF,
nowadays open reduction with rigid fixation is becoming more popular.
ADVANTAGES DISADVANTAGES
• Early return to normal jaw function, normal nutrition, • Need for an open procedure
normal oral hygiene and avoidance of airway problems • Significant operating time and great skill
• Can get absolute stability, promotes primary bone healing required
• Bone fragments re-approximated with direct visualization • Expensive
• Avoids MMF for patients with occupational benefits, • Risk of neurovascular damage
seizures, potential airway problems, psychiatric disorders • Scarring
Endocarditis (NICE guidelines for adults and children undergoing interventional procedures March 2008)
■ Antibacterial prophylaxis and chlorhexidine mouthwash are not recommended for the prevention of
endocarditis in patients undergoing dental procedures.
■ Antibacterial prophylaxis is not recommended for the prevention of endocarditis in patients undergoing
procedures of the:
– Upper and lower respiratory tract (including ear, nose and throat procedures and bronchoscopy)
– Genitourinary tract (including urological, gynaecological and obstetric pr ocedures)
– Upper and lower gastrointestinal tract.
Any infection in patients at risk of endocarditis should be investigated promptly and treated appropriately to
reduce the risk of endocarditis.
■ If patients at risk of endocarditis are undergoing a gastrointestinal or genitourinary tract procedure at a site
where infection is suspected, they should receive appropriate antibacterial therapy that includes cover against
organisms that cause endocarditis.
■ Patients at risk of endocarditis should be:
• Maxilla has 3 paired vertical buttresses which resist the forces of mastication. After traumatic fracture,
intact buttresses provide a valuable rigid support to fix the fractured part: (from anteromedial to
posterolateral)
o Fronto-maxillary
o Zygomatico-maxillary
o Pterygo-maxillary
• Lefort fractures are the fractures of the middle third of the face.
LEFORT I FRACURE
• Transverse fracture of maxilla: a part of body of maxilla separated from the base of the skull above the
level of palate and below the attachment of Zygomatic process
• The fracture extends from nasal septum to the lateral pyriformis rim, travels horizontally above the teeth
apices, crosses below the zygomatico-maxillary junction, and traverses the pterygo-maxillary junction to
disrupt the pterygoid plates.
Clinical features:
• Can occur as single entity or with II & III • Gurien’s sign: Ecchymosis in greater palatine foramen
• Often associated with midline split in the palate (low level fracture)
• Slight swelling of the upper lip • Mobility of the teeth bearing segment of maxilla
• Ecchymosis present in the buccal sulcus • Derangement of occlusion
beneath the zygomatic arch • Gagging of occlused (ANT open bite) as maxilla falls
• Ecchymosis in upper vestibule down posterior teeth clutches so ant mouth remains
open causing lengthening of face
R ADIOGRAPHIC VIEW
• Occipitomental view/PNS view , lateral view, Occlusal view, fronto-occipital view, CT scan
M ANAGEMENT:
• Supportive measures:
o Antral pack
o Antral balloon
• The objective of definitive surgical treatment of maxillary fractures should be fixation of unstable fracture
segments to stable structures usually in the areas of the vertical buttresses. In isolated maxillary fractures,
the stable cranium above and occlusal plate below provide sources of stable fixation.
• In general, restoration of dental occlusion with MMF (with Arch bars and interdental wiring) should be
completed prior to reduction and fixation of other segments of the maxilla.
• In edentulous patients, dentures or surgical splints with circumzygomatic and circummandibular fixation
helps in achieving the occlusal stabilization (MMF will lead to gum ischemia and necrosis in these patients)
COMPLICATIONS
IMMEDIATE COMPLICATIONS LATE COMPLICATIONS
• Airway • Complications arising from head injuries
• Nasal hemorrhage • Complications arising from fracture
• Ophthalmic • Bony deformity
• Cerebral • Lacrimal system
• Inaccurate reduction • Ophthalmic
• Insecure fixation • neurological
• Non-union
ETIOLOGY
• Exact etiology is unknown but it is supposed to be multi-factorial
• Following are considered to be the predisposing factors:
o Irritation due to dentures
o Betel nut chewing
o Tobacco and alcohol
o Ageing
o Role of genetics
o Viral irritants
o Premalignant conditions
o Syphilis
WHO CLASSIFICATION
• Grade 1 : ca in situ
• Grate 2: well differentiated
• Grade 3: moderately differentiated
• Grade 4: poorly differentiated
C/F:
• All oral cancer appear as white red ulcers
• Neck nodes spread: poor prognosis
DX:
• FNAC
• Biopsy: most reliable
• Toluidine blue staining
• Imaging CT scan
M ALIGNANT MELANOMA
• Peak incidence between 40-60 yrs
• Usually appears as black or brown patches
• Amelanotic melanomas appear red
• Histologically consists of neoplastic melanocytes, often surrounded by a clear halo within epithelium and
invading deeper tissues
• Neoplastic melanocytes are round to spindle shaped and typically speckled or intensely pigmented with
melanin
• Shoud be widely excised but median survival probably not>2yrs
LEUKOPLAKIA
• Any white patch of mucosa which is adherent and cannot be given any other clinical diagnosis is a
leukoplakia according to WHO
• White color is due to locked water
• On high power examination: Hyperkeratoiss; Acanthosis; Dysplasia
Rx:
• Regular check-up for changes of colour and ulceration
• Excision
• Cryosurgery
LICHEN PLANUS
• These are lesions of unknown etiology seen in pts (20-60 yrs)
• Commonly occurs in cheek, mucosa tongue and lips
• Lesions appear as white lesion of oral mucosa in reticular pattern
• On histopathology
o Saw tooth appearance of rete ridges
o Infiltration by lymphocytes in connective tissue
o Thickened keratinized layer
• Rx: observation and excision
Dentigerous cyst
Eruption cyst
• Symptoms:
o Pain and swelling
o Salty discharge in mouth
o Mobility/Loosening of teeth (d/t bone resorption)
o Inability to wear dentures
o Missing teeth (teeth won’t erupt)
• Signs:
o Cortical expansion
o Eggshell cracking (d/t destruction of bone)
o Pathological migration of tooth (gap between teeth)
o Alteration in sensation (if neurovascular structures involved)
• Radiological features:
o Radio-opaque sclerotic border (sharp)
o Resorption of root
o Dark shadow where cyst has eroded into the soft tissue
• Diagnosis:
o Aspiration biopsy using wide bore-needle:
Straw colored fluid containing cholesterol crystal dentigerous cyst
Yellowish pus like cheesy material keratinizing cyst
Blood hemangioma
• Treatment:
o Marsupialization:
Decompression
Chances of re-epithelialization and recurrences
Done in case of large cyst or if cyst is near the neurovascular structure or if chances of
fracture of jaw bone
Healing is very slow
o Enucleation:
Always preferred
Remove the entire cyst with its lining
PERIAPICAL CYST
• It is an epithelium lined sac containing liquid or semi-solid inflammatory exudates and necrotic products
• It originates from dental granuloma of infected periapical tissues
Key features:
• Forms in alveolar bone in relation to root of non-vital tooth
• Arise by epithelium proliferation on an apical granuloma
• Usually asymptomatic unless infected
Diagnosis
• Radiographic appearance of non-vital tooth
• Histological appearances
• The cyst has eroded into the mandible, and by its enucleation we risk a discontinuation in mandible
• The cyst is large
• Certain vital structures are involved by the cyst.
Marsupialization is a procedure whereby a new orifice is created by excising a 1 to 2 cm ellipse of tissue that
includes the epithelial surface and the roof of the cyst. The incision is made where the cyst protrudes into the
oral cavity. The edge of the cyst wall is then grasped with fine forceps and everted onto the epithelial surface
where it is sutured with interrupted absorbable sutures, thus creating a passage for draining of glandular
secretions. The cyst/abscess cavity is dressed daily. The cyst is enucleated when it is small enough.
PRIMORDIAL CYSTS
• It is formed due to regression of satellite reticulum in the enamel organ which takes place before any
calcified teeth structure is formed
• It contains keratin tissue
• Usually multi-locular
• From intraosseoulsy, most frequently in post alveolar ridge is angle of mandible;
• Frequently recur after enucleation
• Do not respond to marsupialization
• Radiological appearance usually multi-locular frequently mononuclear
• Histologically: epithelial lining of uniform thickness’ and attached weakly to the fibrous wall
DENTIGEROUS CYSTS
• It is a non-keratinizing odontogenic cyst thought to be of developmental origin, which encloses the crown
of an impacted or unerupted tooth at its neck portion
• Associated with impacted, unerupted (or partially erupted) teeth, commonly in relation to premolars and
molars
• Arising in relation to dental epithelium, such that the crown of the unerupted or impacted tooth lies in the
cystic cavity but the root lies outside
• Clinical features:
nd rd
o Age: mostly in 2 and 3 decade
o Common in lower jaw than upper jaw (2:1)
o Asymptomatic, incidental finding in many cases
o Symptomatic cysts present as painless, smooth and hard swelling on the jaw
o Painful only if infected
o Growing cyst can cause problems of malocclusion, involvement of neurovascular structure, etc
• Radiology: OPG, X-rays (a well-demarcated radioluscent lesion attached at an acute angle to the cervical
area of an unerupted teeth, so should be differentiated from normal dental follicle; tooth seen in the cyst;
soap bubble like appearance due to trabeculations)
• Aspiration with wide bore needle: Straw colored fluid containing cholesterol crystal
• Differential diagnosis: adamantinoma, dental cyst, osteoclastoma
• Treatment:
o Small: excision
o Large: initially marsupialization and later enucleation
o Unerupted teeth should be extracted
• Complications: adamantinoma
During extraction, the periosteal elevator is needed to separate a bone or tooth from the fibrous membrane,
called the periosteum that covers it. The dentist may also use it to gain access to retained roots and
surrounding bone.
ROOT ELEVATORS
Root elevators come in many sizes and shapes. At least one (a nd sometimes more) is used in every tooth
extraction. Which elevator or elevators that are used will depend upon the desire of the dentist. A root
elevator has three functions:
• To loosen the teeth in their sockets.
• To remove parts of teeth (broken root tips or retained roots).
• To remove a complete tooth.
1. Straight root elevator: Its working ends are in line with the handle and have a concave surface. These
are used when the root a re deep-seated.
The beaks of tooth extracting forceps are designed to grasp the tooth with maximum contact on the
facial-lingual surface of the root(s) just below the cervix. The inner surface of each of the two beaks is concave
and the outer surface is convex.
As a general rule, the straight, S- and Z-shaped forceps are used in maxillary teeth while right angled and C-
shaped forceps are used for mandibular teeth.
The beaks are in a straight line with the handle. Because of the straight line of beak and handle, this forceps
allows maximum mobility and application of force.
Maxillary Molars
Because of the unique anatomy of the root of the maxillary molars, the forceps used for their extraction are
also unique, unique in the sense that there are separate forceps for the left and right side. The maxillary molars
have 3 roots: lingual, mesiobuccal and distobuccal. The tip of one of the beaks of this forceps is pointed while
the other is rounded. This arrangement allows for snug fitting of the beaks with the root of the molars: the
beak with pointed end is placed towards the buccal side, with the tip of the beak fitting between the
mesiobuccal and distobuccal roots. The rounded beak grasps the single lingual root. Thus, this forceps is an
anatomical forceps.
This forceps is S-shaped, and while holding the concave surface of the handle should lie on the palm of the
dentist. To identify whether the given forceps is right or left, we have a formula: “Beak towards cheek” i.e.
while holding the forceps with its concave surface on the palm, if the pointed beak is towards the right side, the
given forceps is right sided and vice-versa.
The mandibular forceps are all right-angled. Which of the mandibular teeth they are used for is decided by the
size of the beak. And these differ from the mandibular molars in that the shape of the free-end of the beaks.
Unlike the rounded end of the beaks of these forceps, the ends of both the beaks of the molars are poi nted.
The mandibular forceps are also right angled, they have wide beaks and the free-end of the beaks is pointed so
as to fit snugly between the two roots (mesial and distal) of the mandibular molars.
Cement spatula is used to mix and handle cements and is not used in the mouth. Stainless steel spatulas ar e
used to mix various dental cements, but not with silicate cements (plastic spatulas should be used for silicate
cements).
W AX SPATULAS
These spatulas are heated and then used for handling of wax.
The flattened end is used for tr ansporting the cement while the flat -topped, rounded end is used for plugging
the cement in the prepared cavity.
Burnishing (polishing) means making a surface shiny or smooth by friction. By using a burnisher, the filling
material will be pushed harder so that any small discrepancy between the restoration and the tooth is closed.
This action will polish and level the margins of restorations.
EXCAVATOR
It is used to remove any caries and other debris from the tooth cavity while preparing for restoration.
Pigtail explorer
COTTON PLIERS
These are metallic forceps whose working ends make an acute angle with the handle. As their name suggests,
they are used for transporting cotton rolls, cotton gauze or other things into and out of the mouth.
Used for clear visualization of those areas of teeth which are beyond the direct line of vision. They can either be
plane mirror (image of same size) or magnifying mirror (magnified image).