Dentistry Final

Dental notes
A complete note for the final year MBBS
TABLE 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
Mandible
Tooth extraction
Dentine
Gingivitis vs periodontitis - Very Very
FAQ
Antibiotics prophylaxis in ie and rhd
Eruptions date for deciduous permanent
dentition FAQ
Dental Notes by Sadichhya, Shooga & Sumesh
Middle third fracture

Nerve supply: inferior alveolar nerve
Dental hygiene: tooth brushing FAQ
Dental notation
Dentigerous cyst
Chronic injuries - FAQ
False and true pocket
Hypersensitive tooth: pulpitis

Fluoride toothpaste - FAQ
Medical assessment of dental
procedure
Calculus and plaque
Dentoalveolar abscess
Pericoronitis
Downloaded from DigitalMedicine.com.np
INTRODUCTION TO DENTISTRY
Definition: Diagnosis, prevention, and treatment of diseases of the teeth, gums, and related structures of
the mouth and face including the repair or replacement.
Branches of dentistry:
1. Oral medicine and radiology: Concerned with diagnosis and treatment planning of acquired and
inherited disorders and diseases of the orofacial region
2. Conservative Dentistry and Endodontics: Deals with the prevention, diagnosis and treatment of
the diseases affecting dental and periapical tissues
3. Orthodontics and Dentofacial Orthopedics: Study and treatment of malocclusions (improper bites)
4. Periodontics and implantology: Prevention, diagnosis and treatment of diseases of tooth
supporting tissues and Implants for replacement of missing teeth
5. Maxillofacial Prosthodontics: Replacement of missing teeth, mouth, jaw and facial structures with
artificial substitutes like dentures, crown and bridges.
6. Oral and Maxillofacial Surgery: Treats conditions, defects, injuries of the mouth, teeth, jaws, and
face
7. Pedodontics and preventive dentistry: Deals with the treatment of childrens teeth
8. Community Dentistry: Public health aspect of dentistry like health programs, screening, etc.
9. Oral pathology Deals with investigation of causes, processes and effects of the diseases that
affect the oral and maxillofacial tissues.
10. Forensic Odontology: Proper handling, examination and evaluation of dental evidence, which will
be presented in the interest of justice
ORAL CAVITY
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.
Dental Notes by Sadichhya & Shooga
DEVELOPMENT OF TEETH
STAGES OF TOOTH DEVELOPMENT

1. Bud stage
Teeth arise from epithelial mesenchymal interaction between overlying oral epithelium and underlying
mesenchyme derived from neural crest cells.
6th week: basal layer of epithelial lining of oral cavity forms a c-shaped structure called the dental lamina
along the length of upper and lower jaw
Lamina gives rise to 10 Dental Buds in each jaw: primordial of ectodermal component of teeth
Buds for permanent teeth lie on lingual aspect of milk teeth, formed during3rd month of development
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
When enamel thickens, ameloblasts retreat into stellate reticulum where they regress, temporarily leaving
thin membrane called dental cuticle on the surface of enamel which sloughs off after eruption.
When dental epithelial layers penetrate in to underlying mesenchyme, root is forms
o First epithelial root sheath is formed
o Cells of dental papilla lay down a layer of dentin continuous with that of crown.
o As dentin increases, pulp chamber narrows forming canal
o Mesenchymal cells on outside of tooth differentiate into cementoblasts which produce cementum
o Outside the cementum, mesenchyme gives rise to periodontal ligament
DENTAL ANATOMY
FUNCTIONS OF TEETH
Mastication: cutting, piercing, grinding

Helps in deglutition
Articulation of Speech
Cosmetic/ Aesthetic
Defensive
PARTS OF TOOTH
Crown
Cervical Line
Root
OCCLUSAL LINE, MESIAL LINE AND THE FOUR QUADRANTS

Mesial Line
RUQ
LUQ
RLQ
LLQ
Occlusal Line
ANTERIOR AND POSTERIOR TEETH
Demarcation line: junction of lips and cheek

Central Incisors, Lateral Incisors and Canines are anterior teeth (they are adjacent to lips)
Premolars and molars are posterior teeth (they are adjacent to cheeks)
SURFACES OF TOOTH
1.
2.
3.
4.
5.
Mesial surface: Towards the midline along the arch

Distal surface: Away from the midline along the arch
Facial surface: i) Labial surface (anterior teeth) or ii) Buccal surface (posterior teeth)
Lingual surface: In maxillary teeth, it is also called as the palatal surface
Occlusal surface (poorly defined in anterior teeth, incisal edge)
DENTAL ARCHES
Maxillary/ upper arch

Mandibular/ lower arch
CLASSIFICATION OF TEETH
Incisors
Canines
(Cuspid)
Premolars
(Bicuspids)
Molars
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.
Pointed Edge(cusp), pierce meat, small size in F (4 surfaces + 1 cusp)
1 root
Intermediate function of canines and molars (5 surfaces ) have 2 cusps: buccal cusp and lingual
cusp (also called palatal cusp in maxillary premolars)
st
2 roots (buccal and palatal) in 1 maxillary premolars, all others have 1 root
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)
Incisors
Canines
Premolars
Molars
HUMAN DENTITION
Humans have diphyodont dentition (having two sets of teeth, a primary and a permanent set)
Period of primary/ deciduous dentition: 6mth-6yrs

Period of mixed dentition: 6yrs-12yrs
20 temporary teeth replaced by 32 permanent teeth
Molars of temp teeth replaced by premolars of permanent teeth
M1, M2, M3 do not succeed their counterparts; they come behind deciduous teeth and are known as nonsucceedaneous. Rest of the teeth are succeedaneous.
Primary Dentition (Temporary Teeth)

Milk teeth: white as milk/ occurs during
breastfeeding
Deciduous: falls of
Primate spaces: Mesial to upper Canine, Distal to
lower canine
Dental Formula :
2102
Total = 20
2102
Eruption Dates:
Incisors: Lower central : 6 mths
o Lower lateral: 7 mth
o Upper central: 7 mth
o Upper Lateral : 8 mth
1st molar: 12-16 mth
Canines: 16-20 mths
2nd molar: 2-2 yrs
First to shed off: Lower central incisor: 6 yrs
Last tooth to shed off: 2nd molar/canine: ~12 yrs
Secondary Dentition (Permanent teeth)

Dental Formula
2123
Total = 32
2123
First to appear: Lower central incisor/ First molar
Last to appear: Third molar
Eruption dates:
Incisors: Lower central : 6-7 yrs
o Lower lateral: 7-8 yrs
o Upper central: 7-8 yrs
o Upper Lateral : 8yrs
1st molar: 6 yrs
2nd molar: 12 yrs
3rd molar: 17-23 yrs
Premolars: PM1: 9yrs ; PM2: 10 yrs
Canines: 11-12 yrs
ERUPTION DATES OF DENTITION (THESE ARE ACCORDING TO CLASS PRESENTATION)
Primary dentition
Central incisor
Lateral incisor
First molar
Canine
Second Molar
Lower Jaw
6 months
7 months
10 12 months
16 months
20 months
Upper Jaw
7 months
9 months
14 months
18 months
24 months
Permanent dentition
Central incisor
First molar
Lateral incisor
Canine
First Premolar
Second Premolar
Second Molar
Third molar
(Wisdom tooth)
Lower Jaw
6-7 Yrs
6 yrs
7-8 yrs
9-10 yrs
Upper Jaw
7-8 yrs
6 yrs
8-9 yrs
11-12 yrs
(After PM2)
10-12 yrs
10-11 yrs
11-12 yrs
10-12 yrs
12 yrs
12 yrs
17-23 years
6
INTERNAL STRUCTURE OF TOOTH
Enamel
Dentine
Pulp
Radicular Pulp
Cementum
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 pulpbrain-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
Highly vascular delicate connective tissue derived from dental papilla.
Contained within pulp cavity which includes:
o Pulp chamber in crown: contains coronal pulp
o Root canal in root: contains radicular pulp

Pulp horn: pulp going towards the cusps
At the apex of the root is an apical foramen thru which passes blood vessels, nerves and lymphatics.
Functions of pulp:
o Denture formation
o Nutrition of all parts of tooth
o Defense
o Sensory (inflammation: swelling: press in pulp: very painful)
Odontoblastic processes may act as sensory receptors in dentine.
Pain of pulpitis
Cannot localize
Pain of periodontitis
Can localize because periodontal ligament has
nerves with proprioceptive fibers.
PERIODONTIUM
It consists of:
1. Supporting tissues (Attachment apparatus):
a. Alveolar Bone
b. Cementum
c. Periodontal Ligament
2. Investing tissue:
a. Gingiva or Gum
Alveolar bone
Periodontal
ligament
Cementum
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
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
Contains fibroblasts, reticulin fibers. Poorly organized collagen fibers and ground substance, rich network
of capillaries, plexus of myelinated nerve fibers.
Cementum is thicker towards apex
Softer than dentine (55% inorganic material but harder than bone 45%)
rd
rd
Apical 1/3 is cellular (i.e. cells cementoblasts present) while remaining coronal 2/3 is acellular.
Cementum contains cells known as cementoblasts
Function: Sharpeys fibers hold teeth with periodontal membrane and have cushioning effect.
Periodontal membrane fixes the tooth in its socket and contains numerous nerve endings. BV also acts as a
shock absorber: part of force during mastication is dissipated by its ligament.
Alveolar Bone
Alveolar arch
Interdental septum
Intra radicular bone
Periodontal Ligament
Functions
o Support
o Shock absorber
o Propriocpetion
o Formative
o Nutrtion
CLINICAL DENTAL NOTATION

PALMER NOTATION METHOD (ZSIGMONDY SYSTEM)
Hungarian dentist Adolf Zsigmondy

87654321 | 12345678
EDCBA | ABCDE
R-------------------------------L R--------------------------L
87654321 | 12345678
EDCBA | ABCDE
Permanent Dentition
Deciduous Dentition
Used in Nepal, but cant be entered in computer

Permanent teeth : 1-8
Temporary teeth: A-E
FDI (FDRATION DENTAIRE INTERNATIONALE)/ WORLD DENTAL FEDERATION NOTATION
Used two numbers to denote each tooth.

First number denotes the quadrants:
1 |
2
R--------------------L
4 | 3
5 | 6
R--------------------L
8 | 7
Permanent Dentition
Deciduous Dentition
The second number denotes the number of the tooth:

87654321|12345678
R -----------------------------------------------------L
87654321|12345678
Permanent dentition
54321|12345
R -----------------------------------L
54321|12345
Deciduous dentition
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:
upper right - 1x
upper left - 2x
18 17 16 15 14 13 12 11 | 21 22 23 24 25 26 27 28
R --------------------------------------------------------------------L
48 47 46 45 44 43 42 41 | 31 32 33 34 35 36 37 38
lower right - 4x
lower left - 3x
Thus, the deciduous dentition will have the following notation:

upper right - 5x upper left - 6x
55 54 53 52 51 | 61 62 63 64 65
R ------------------------------------------- L
85 84 83 82 81 | 71 72 73 74 75
lower right - 8x lower left - 7x
UNIVERSAL NUMBERING SYSTEM
A single number to denote each tooth. The continuous numbering from 1 to 32 is used for the permanent
dentition and alphabets A to T are used for the deciduous dentition. (Mostly used in the US)
1 2 3 4 5 6 7 8 | 9 10 11 12 13 14 15 16
ABCDE | FGHIJ
R ------------------------------------------------------------------------L
R --------------------------- L
32 31 30 29 28 27 26 25 | 24 23 22 21 20 19 18 17
TSRQP | ONMLK
Permanent Dentition
Deciduous Dentition
10
ORAL HYGIENE
INSPECTION OF ORAL CAVITY
Status of oral hygiene judged by inspection of oral cavity for:

o Food debris
o Teeth:
Plaques
Calculus
Stains
Caries
o Gum:
Gingival inflammation
Gingival pocketing
Gum recession
o Breath
On the basis of these characteristics the status of oral hygiene is labeled as:
o FAIR
o AVERAGE
o POOR
Fundamental requirement of oral aids: Aids to oral hygiene should be capable of removing dental plaques
without any damage to hard and soft tissues
METHODS OF CLEANING
1.
2.
3.
4.
Mechanical cleaning:
Brushing with a tooth brush
Dental floss
Massage to gum
Wood pecks
Chemical cleaning
Chlorhexidine
Change of diet:
Low sugar content
Scaling:
Manual (conventional scaling)
Ultrasonic
REQUIREMENTS OF A TOOTH BRUSH
Small
Size:
o for adults: head length 2.5cm
o for children: head length 1.5 cm
Bristles should be of even length (1cm)
o Concave, convex or zigzag have no beneficial effect
o Short bristles are rigid and can cause trauma
o Tufts of bristles should be loosely packed
o Each tuft should contain 30-35 bristles
Texture of brush:
o Soft: doesnt remove plaque
o Medium: preferred
o Hard: cause gingival recession: good for smokers who have tobacco stained teeth
Angulation: doesnt have extra benefit
REQUISITES FOR SATISFACTORY BRUSHING
Should clean all dental surfaces including gingival crevices

Shouldnt injure tissues and shouldnt cause gingival recession
Should be simple, rapid
Should be well organized
Should fit patients capabilities
11
Each jaw should be divided into 2 quadrants; each quadrant is further divided into:
st
1 segment: incisor and canine
nd
2 segment: premolars
rd
3 segment: molars
BRUSHING TECHNIQUE:
Different techniques:
1. Vertical
2. Horizontal
3. Vibratory
4. Rolls method (sweep method)
5. Bass method (sulcular method)
6. Modified Bass method
7. Charters method
8. Modified Stillmans 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
Rolls 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
12
After these types of food, have to brush immediately within half an hour
o Polysaccharide: doesnt cause problem
o Disaccharide and monosaccharide: decreases pH immediately and cause dissolution of mineral,
forming caries
During sleep BMR decreases so saliva production decreases: cant wash away the food particles: cause
decreases pH: minerals are dissolved : l/t caries
Cultural factor: brushing in the morning
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
CHEMICAL CLEANING OF TEETH
Chlorhexidine gluconate 0.1-0.2% mouthwash reduces salivary bacterial count by 20-50% and inhibits
plaque formation over a prolonged period
SCALING
Removes both supra and sub gingival calculi
13
Two methods:
o Manual/conventional scaling
o Ultrasonic scaling
Ultrasonic scaling:
o Tip of instrument vibrates in high speed (20-20KHz)
o Calculus is fractured
o Use of water to nullify heat produced that can otherwise damage teeth and also for flushing
action
Scaling should be followed by polishing (otherwise rough surface can harbor plaque)
Sublingual plaque maybe be left behind by ultrasonic scaling so check and mechanical scaling should be
performed
14
DENTAL PLAQUE
Definition: WHO (1978): Specific but highly variable structural entity resulting from sequential colonization
& growth of micro-organism of various species & strains embedded in an extracellular matrix.
Tenaciously adherent soft deposit composed of bacteria in an organic matrix.
Thin plaques are invisible while the visible plaques are thick plaques
Forms nidus for formation of dental calculus and bacterial growth
Not removed by water rinsing
Cleared by frictional force: e.g. Brushing
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 to the tooth surface and cant 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 positive cocci
o Strep mutans, viridians, milliri, mitis
o Staph aureus, albus, pyogenes
(facultative)
o Pneumococcus (facultative)
Gram positive bacilli
o Lactobacillis acidophilus
o Odentophytic, fermenti.
Gram negative cocci (facultative)

o Neisseria gonorrhea, meningitides
o Morexella cattarhalis
Gram negative bacill (facultative)
o Actinobacillus Actinomycetemcomitans
o Campylobacter rectus
o Eikenella corrodens
o Enteric rods
o Pseudomonas
15
Anaerobic Gram negative rods

o Porphyromonas gingivalis
o Prevotella gingivalis
o Bacteroids forsythus
o Fusobacterium species
Anaeronic Gram positive rods
o Eubacterium species
Anaerobic Gram positive cocci
o Peptostreptococcus micros
Organic and inorganic matrix
Inorganic: Ca, Na, K, PO4
Interbacterial matrix: Dextran, Hexosamine,
Levan, methyl pentose, and galactose
Fungi
Candida albicans
Parasites (facultative)
Entamoeba gingivalis
Spirella
Leptotrichia
Buccalis
400 million organisms are found per milligram of dental
plaque
Organic: protein, -CHO, lipid, desquamated

epithelium, leucocytes, food particles
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
SEQUEL OF DENTAL PLAQUE
On the tooth dental calculus

On the tooth dental caries Dentine exposure (sensitive tooth)pulpitisperiapical abscess (tender
tooth
On the gingiva gingivitis periodontitis
16
DENTAL CALCULUS
Hard deposits formed on tooth or dental appliances due to mineralization of dental plaque
Color: normally yellowish white but may get stained with tea, coffee, drugs, smoke, etc giving dark brown
to black coloration
In relation to gingival margin: dental calculi can be
o Supra-gingival
Coronal to gingival margin towards crown
Hard clay like consistency
White or yellowish white (Stain)
st
nd
Abundant on buccal surfaces of upper 1 and 2 molars & lower lingual surfaces
Formed in 2 weeks
o Sub-gingival
In gingival sulcus, identified by probe and air syringe
Thinner, harder.
Greenish black or dark brown to black
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.
17
DENTAL CARIES
Definition: Progressive irreversible damage to hard part of the teeth exposed to oral environment
characterized by demineralization of inorganic constituents and dissolution of organic contents resulting in
cavitation.
One of the commonest diseases in the world

Enamel, dentine, surfaces adjacent to tooth restorations and exposed roots are susceptible areas
NATURAL HISTORY OF DENTAL CARIES
1.
2.
3.
4.
5.
6.
7.
Initial enamel subsurface demineralization due to bacterial acid Extension of demineralized zone
towards dentine Collapse of surface layer to form cavity Extension of caries lesion into dentine
Extension of caries into pulp (with possible formation of apical abscess)
Enamel caries: discoloration (asymptomatic chalky white soft spot on tooth), catch on probing (if only
stain no catch), cavitation and soft consistency on probing (leathery feel)
Dentinal caries: features of enamel caries + sensitivity
Pulpitis: features of dentinal caries + pain (inflammation of pulp causes stimulation of A & C-fibres)
Periapical periodontitis: features of pulpitis + tenderness on percussion (periodontial ligament space is
filled with exudate lifting the tooth)
Periapical abscess: features of periapical periodontitis + swelling
Sequel of periapical abscess:
a. Sinus tract formation
b. Periapical granuloma
c. Periapical/Periodontal cyst
d. Ludwigs angina
e. Osteomyelitis and periostitis
f. Cavernous sinus thrombosis
As dentine and enamel dont have blood supply, natural healing doesnt occur
Aim of treatment is to stop progression
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, Stephans 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
Stephans 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
18
3.
Proteolysis-chelation theory (latest)

Latest theory, widely accepted
Bacterial attack on enamel is initiated by keratolytic microorganisms: breakdown of proteins
and other organic portion of enamel especially keratin
This results in formation of substance which may form soluble chelates with mineralized
portion of teeth: organic and inorganic portion of tooth undergo demineralization
simultaneously
Chelation is complexing or freeing metallic ion
Factors responsible for caries
1. Role of microorganism (E.g., long-term antibiotics use is protective against caries)
2. Role of carbohydrates (sugary diet increase the risk of caries)
3. Role of acids to demineralize
4. Role of dental plaque (Acid that is formed is kept in contact with teeth surface for longer time)
5. Role of teeth surface (less fluorhydroxyapatite and irregular teeth increase risk of caries)
6. Role of salivary flow (hypersalivation is protective against caries)
STEPHANS CURVE AND CARIES
The Stephans curve describes the pH change in relation to the food intake (Critical pH for caries formation is
5.5). The second figure shows the Stephans curve according to different salivary flow rate.
1.
2.
3.
4.
5.
Stephan Curves describe the changes in pH occurring within dental plaque when it is subjected to a
challenge, typically with a foodstuff
When challenged with a fermentable carbohydrate the pH within plaque drops rapidly and then rises back
to the resting pH more slowly
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
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.
The relationship of the shape of the Stephan Curve to the Critical pH can be used to assess the relative
cariogenicity of foods
CARIOGENIC 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
19
o Propionic acid
Disaccharides are more cariogenic than monosaccharides
Glucose and fructose through unrefined foods can be severely cariogenic (less than sucrose)
MANAGEMENT
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 CARIES
Complete removal of plaque
Brushing
Scaling
Denial of substrate to plaque bacteria
Avoid soft, sugary and sticky diet, and brushing once any food gets stuck (4S) (artificial sweeteners are not
Cariogenic because they cannot be fermented by bacteria)
Modifying plaque
Addition of Na, Ca phosphate to Cariogenic diet decreases caries in animals
Increasing resistance of tooth to bacterial action
Antibacterial measures
o Antibiotics prevent caries but use is not advisable only for this purpose e.g. penicillin in long term
with RHD
Antiseptics: e.g. Chlorhexidine gluconate 0.2% mouthwash
o Mechanism: destroys cell membrane of bacteria
o Disadvantages: not very effective as on stopping its use, causes growth of bacteria again
o If long term use: extrinsic discoloration (staining) but no other harmful affect
o Very unpleasant taste
Immunization against caries: still in experimental stage, vaccine not yet developed as it is not practical
since many organisms are responsible
Roles of fluorides: (double edged sword)
Addition of fluoride to water 1PPM most effective means of increasing resistance of tooth to bacterial
action
If addition of >2PPM fluoride: fluorosis: enamel mottling of teeth, opaque tint, and pitted stained,
more brittle.
Ways of taking fluoride: Systemic and Topical.
Systemic application of fluoride
o Water fluorination (1PPM in water supply)
o Salt fluorination(1/2 to 1/3 water concentration_
o Milk fluorination
o Fluoride tablets
Dual effect: systemic as well as local
One tab: 2.2 mg of NaF (O.D) : equivalent to taking 1L of water containing 1PPM of
fluoride
Started immediately after birth
Up to 2yrs: 1.1 mg (1/2 tab daily)
20
2-12 yrs: 2.2 mg daily one tab

>12 yrs (1/2 tab daily)
Topical application of fluoride
o Get incorporated into superficial enamel which is available in the following forms
Fluoride mouth rinse
Fluoride containing dentifrice: gel, powder, paste
Shouldnt rinse vigorously after brushing (residual fluoride after brushing)
Fluoride tablets
Fluoride in toothpaste
Most formulation contains NaF (sodium monoflouride) or capil (sodium
mono fluorophosphates) or combination of both at a concentration of 1000
or 1500 ppm used twice daily, this will reduce caries incidence around 30%
o Tooth paste of children formulation 125 to 580 ppm fluoride. Up to 4
years, non-fluoridated toothpaste because it can be toxic if swallowed.
Advantages: Directly in contact with teeth; Used everyday
Disadvantage: casual process, only in accessible areas
Mechanism of Action of Fluoride

1.
2.
3.
4.
5.
Formation of fluorhydroxyapatite which makes enamel stronger and acid-resistant (Hydroxyapatite +

fluoride -> fluorohydroxyapatite crystals which are larger and have few imperfections)
Enhancement of remineralization at crystal surfaces of the tooth
Reduce demineralization
Inhibit enolase enzyme in glycolytic cycle of the bacteria thereby preventing acid generation.
Changes in morphology of the teeth (esp. if fluoride is present during development of teeth)
DIFFERENT TYPES OF X-RAY MODALITIES USED IN DENTISTRY
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/Waters view for PNS
o Submento vertex view: for zygomatic process
o PA skull
o Transpharyngeal view for TMJ
o Townes view and reverse Townes 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.
21
PERIODONTAL DISEASES AND GINGIVITIS
Periodontal disease: A group of diseases that affect all the periodontal structures. It results in destruction
of attachment apparatus, development of periodontal pocket and progressive loss of alveolar bone.
1999 Classification of periodontal diseases:
1. Gingivitis
2. Chronic periodontitis
3. Aggressive periodontitis
4. Periodontitis as a manifestation of systemic disease (eg, leukemia, cyclic neutropenia, EhlersDanlos syndrome)
5. Necrotizing ulcerative gingivitis/periodontitis
6. Abscesses of periodotium (periodontal abscess, gingival abscess and pericoronal abscess)
7. Combined periodontic - endodontic (pulp) lesions
Gingivitis: Inflammation if gingival tissue associated with signs and symptoms of inflammation i.e. rubor,
calor, dallor, tumor, etc.
It is the sequlae of dental plaque and dental calculus
CAUSES:
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: 3D 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.
2.
3.
4.
Acute Necrotizing Ulcerative Gingivitis (ANUG)

Herpetic gingivitis
Non-specific or streptococcal gingivitis
Leukemic gingivitis
ACUTE NECROTIZING ULCERATIVE GINGIVITIS (ANUG)
Also referred to as Vincents angina or trench mouth

Organisms
o Borrelia vinceti (Treponema vinceti)
o Bacillus fusiformis
o Gram negative anaerobes
o Other bacteria like vibrio, bacterioids and melaninoginicus
Age groups affected
o Children not usually affected
o Adults and adolescents more
22
In developing countries, incidence is high in children due to prevalence of measles, malnutrition

and malaria (3M)
Risk factors
o Smoking
o Improper oral hygiene
o Anxiety and stress
o Alcohol use
Clinical Features
o Local (aka Vincents infection)
o Sudden gingival inflammation, ulceration, bleeding, Interdental gingival necrosis, and fetid
halitosis
o Ulceration and necrosis of Interdental papillae
o Punched out ulcer-crater like formation covered with grayish white membrane or slough
o Very painful
o Halitosis, metallic taste, and increased salivation
o General: fever, malaise, lymphadenitis
Management
o Debridement wash in H2O2 ( it cleans necrotic tissue due to O2 release, also it is lethal to anaerobic
bacteria) or Chlorhexidine gluoconate mouthwash
o Metronidazole 250-400 mg TDS 5-7 days
o Amoxicillin 250-520 mg TDS 5-7 days
o Rest, soft food
o Analgesics
o Antipyretics
o
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
STREPTOCOCCAL/ NON-SPECIFIC GINGIVITIS:
Due to streptococcal infection from oral commensals itself

Clinical Features
o beefy red lesions, painful
o increased salivation
o saliva cant be swallowed: so trickle down from corner
o no ulceration, no necrosis
Management
o Tetracycline 250 mg OID 5 days
LEUKEMIC GINGIVITIS
Painful, swelling of gum and spontaneous bleeding

Anemia and lymphadenopathy
23
Management
o Symptomatic treatment
o Prevent secondary bacterial infection
o Gingivoplasty: reconstructing and reshaping (reconstructing) of gingiva
o Gingivectomy: excision of diseased part of gingiva
o Sequlae of gingivitis: periodontitis
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
24
PERIODONTITIS
Inflammation of periodontium
Periodontal disease accounts for more teeth loss then caries, especially in elderly
Chronic infection of gingiva and anchoring structures begins with formation of bacterial plaque: begins
above gum line in gingival sulcus
Two types: acute and chronic
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 Vincents 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
25
Clinical Features
o Features Of Periodontal Damage
1. Apical migration of gingiva exposing root (gum recession)
2. True pocket
3. Mobile teeth
o All features of chronic gingivitis
o Pus can be squeezed from around the neck of teeth (foul smelling)
o Halitosis
o Teeth may be mobile or loose ending on amount of alveolar bone resorption
Diagnosis
o Features of chronic gingivitis + at least one feature of periodontal ligament damage
Principles of Management
o To control gingival infection
1. removal of soft and hard deposits from pockets
2. maintain oral hygiene
3. removal of false pockets
o To eliminate periodontal pockets:
1. Sub-gingival curettage of pocket to from normal attachment of gingiva
2. Gingivectomy or Gingivoplasty
o Mucogingival flap operation: curettage of granulation tissue dead bone and damaged cementum
beneath the flap
Complications
o Dentoalveolar abscesses (oral and intra oral abscesses):
o Bacterial, septicemia, pyemia
o Cellulites of face
o Lymphadenitis (acute)
o Osteomyelitis of jaw
o Sinusitis (maxillary)
o Scar on cheek and face
26
DENTOALVEOLAR ABSCESS AND PERIODONTAL ABSCESS
Dentoalveolar abscess:
1. Gingival abscess
2. Periodontal abscess:
a. Periapical abscess: due to infection around the root or root apex
b. Lateral abscess: due to infestation of gingival sulcus due to impaction of food
particles or trauma
3. Pericoronal abscess (aka pericoronitis)
4. Combined periodontal / endodontric abscess
CLINICAL FEATURES OF PERIODONTAL ABSCESS
Severe throbbing pain

Patient cannot close teeth together due to slightest elongation (edema)
Very tender to even light touch
Fluctuant swelling in the buccal, labial lingual or palatal region depending upon the teeth involved
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
Differences between two types of periodontal abscess:

Lateral abscess
Periapical abscess
1. Defn: Accumulation of pus along the root surface
1. Defn: It is collection of pus in alveolar bone
of a tooth that originates from infection in
at the root apex following death of the pulp.
supporting structure of the tooth.
2. Associated with periodontal pocket.
2. Not
3. On pressure, pus may exude near edematous
tissue or through sulcus.
4. Swelling is usually located opposite the
midsection of the root & gingival border.
5. Generally associated with vital teeth.
6. Treatment : I & D
3. Not
4. Located opposite the root apex or beyound
it.
5. Associted with pulp less or non vital teeth.
6. Treatment : RCT
27
IMPACTED TEETH
Obstruction in normal mechanism of eruption of teeth

Soft tissue overlying occlusal surface of teeth is called operculum
Impacted tooth can be at certain angulations
In erupting and impacted tooth tissues are present around the crown
Impaction can be
o Soft tissue impaction
o Hard tissue impaction
Space may not be available for tooth to erupt: impacted
28
PERICORONITIS
Inflammation of soft tissue around the crown of erupting tooth or impacted tooth.
When eruption is complete there is an opening through the membrane, the rest of the crown is covered by
a flap of soft tissue known as operculum
rd
Can occur un any tooth at any age but commonly occurs in lower 3 molar at the age of 18-24 years
CAUSES
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.
Vincents 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
MANAGEMENT
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 doesnt have good occlusion with antagonist teeth
4. Removal of upper teeth if pain
29
PULPITIS
Inflammation of the dental pulp.

Very painful condition and is the most common cause of sever dental pain
If untreated: death of pulp -> spread of infection to periodontal space -> periodontitis
ETIOLOGY:
Dental caries: extending up to pulp (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
Aerodontalgia: mimics pulpitis pain but is due to decompression in high altitude
PATHOGENESIS:
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
Grossmans 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
30
b.
c.
Hyperplastic pulpitis
Internal resorption
ACUTE CLOSED PULPITIS
When virulent microorganisms enter the pulp in large numbers, part of pulp becomes quickly destroyed
resulting in an acute inflammatory reaction.
This reaction leads to acute hyperemia with escape of fluids and cellular exudates into the surrounding
tissues
A minute abscess is formed
Rest of pulp is undamaged i.e. infection remains localized
In severe cases, however inflammation doesnt remain localized: it spreads quickly to pulp and
progressively destroys it.
CHRONIC CLOSED PULPITIS
Pulp destruction is seen at the entry at site of injection

Mild hyperemia and abscess formation occurs
Infection can remain localized for long periods with remaining part of pulp infected and healthy
In other words, destruction progresses slowly and finally thru apex, reach periapical tissue
Clinically acute and chronic pulpitis recognized by type and degree of pain:
o Acute pulpitis:
Early stage: tooth is hypersensitive to hot and cold
Later: pain becomes more persisted and aggravated while lying down or sleeping
Pain is due to: pressure on nerve endings by inflammatory exudates in the closed and
rigid pulp chamber OR release of pain producing mediators (histamine, 5-HT) from
damaged site
o Chronic pulpits:
May develop without symptoms
However there may be bouts of full pain with hot and cold stimuli spontaneously
Pain of both acute and chronic pulpitis is poorly localized due to lack of proprioceptive fibers in the pulp
and because individual pulp is not represented in sensory homunculus.
ACUTE OPEN PULPITIS
It occurs in late stage of caries

Pulp chamber may open up due to destruction of part of crown
Usually the pulp is already dead by this time but it may remain viable and proliferative
Following an acute exposure and introduction of infection, an acute inflammatory reaction ensues that
leads to abscess formation and escape of pus thru to exposed part
Pus escapes: pain relived
Rapid spread of infection and destruction of pulp
CHRONIC OPEN PULPITIS
Occasionally widely exposed pulp survives in a stage of chronic open pulpitis especially in teeth with open
apex
Chronic hyperplastic pulpitis (CHP): It is a productive pulpal inflammation due to an extensive carious
exposure of a young pulp and characterized by an overgrowth of the tissue outside the boundary of pulp
chamber as a protruding mass, resulting from long standing, low grade irritation.
Crown of tooth with pulp are destroyed and replaced by granulation tissue which may proliferate to fill the
carious cavity and then undergoes epithelialization and fibrosis leads to formation of nodules called
pulp polyps
CHP: irritation, infection, chronic inflammation of pulp, proliferation of granulation tissue, epitelization and
fibrosis
Painless , occurs usually when apex is wide open and high blood supply maintain viability
Pathophysiology of chronic open pulpitis:
o Infection: chronic inflammation of pulp: formation of granulation tissue and proliferation:
epithelization and fibrosis: nodule formation
31
INVESTIGATION AND DIAGNOSIS
Thermal test (see by applying hot and cold): Initially tooth is sensitive to both hot and cold but later the
cold relives while hot aggravates
Electric pulp tester:
o First test in a healthy tooth
o Start with low current and raise it till response comes
o Then test in affected tooth
o Low current produces responds in early stage and high current in late stage
o Helps to judge the extent of pulpitis
MANAGEMENT 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
TREATMENT MODALITY FOR DIFFERENT TYPES OF PULPITIS

Reversible Pulpitis
Superficial caries: restoration
Deep caries: restoration with base
Very deep caries: IPC
Exposed pulp: DPC or Pulpotomy
Acute pulpitis
DPC
Post and core
RCT
Extraction
Chronic pulpitis
Post and core
RCT
Extraction
Chronic hyperplastic pulpitis

Elimination of polypoid tissue
(with periodontal curette or spoon
excavator) followed by RCT
Extraction
TREATMENT OF PULPITIS IS OFFERED BASED ON PATIENT
Attitude: whether he wants to preserve or remove the tooth

Financial status: RCT is expensive
Latest technique for desensitization : iontophoresis (back to condition of sensation)
Once irreversible pulpitis occurs: RCT is necessary and contents of pulp chamber and root canals are
removed followed by thorough cleaning antisepsis and filling teeth with an inert material
COMPLICATIONS OF PULPITIS
If pulp infection doesnt 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 (Ludwigs 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.
32
MALOCCLUSION
NORMAL OCCLUSIONS
Incisor occlusion
o Overjet: horizontal distance between upper and lower incisor normally is 2-3 mm
o Overbite: vertical displacement of upper incisor over lower, normally it is 2-3 mm
Canine
o Upper canine fits in the groove behind distal margin of lower canine
Molars:
o Cusps of upper molars fit in the grooves of fossa of lower molars
ANGLES CLASSIFICATION OF OCCLUSION

Based on the relationship of mesiobuccal cusp of upper first molar to buccal groove of lower first molar
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
MALOCCLUSION
Increased overjet, Increased overbite

Class III or class II occlusion
Requires orthodontic treatment: braces
TREATMENT
Photography
Dental caries prepared
Separators placed and Braces Kept
33
CHRONIC INJURIES TO TEETH
Conditions that are taking place over a long period of time especially in the elderly
Include attrition, abrasion and erosion
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
34
Treatment:
o Identification of course (occupational, etc.) and its avoidance
o Coatings
o Fluorinated tooth paste
o Inotophorosis (Na , F)
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
35
DIFFERENT TYPES AND CAUSES OF RESORPTION
Internal resorption gross

appearance
Cyst
Internal resorption
in x-ray
Periapical inflammation
Impacted teeth
36
DISLOCATION OF TEMPOROMANDIBULAR JOINT

TYPES:
Acute dislocation
Chronic dislocation
CAUSES
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
MANAGEMENT
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
37
ANESTHETIZATION
TRIGEMINAL NERVE AND ITS BRANCHES
I.
II.
Fifth cranial nerve

Largest cranial nerve
Mixed nerve with 2 roots:
Sensory: Skin of the face and mucous membrane of cranial viscera and oral cavity
Motor:
o Masticatory muscles- massetter, temporalis,
medial pterygoid, lateral pterygoid
o Mylohyoid
o Anteriror belly of digastric
o Tensor tympani
o Tensor veli palatini
OPHTHALMIC NERVE
Purely sensory
Smallest branch
Leaves the cranium and enters the orbit through
superior orbital fissure.
SUPPLIES
o Eyeball, conjunctiva
o Lacrimal gland
o Parts of the mucous membrane of the nose &
Para nasal sinuses
o Skin of the forehead, eyelids & nose
Branches of ophthalmic nerve:
o Lacrimal nerve is the smallest branch of the opthalmic division. It supplies the lateral part of upper
eyelid and a small adjacent area of the skin.
o Frontal nerve:
Supratrochlear: supplies conjunctiva and skin of the medial aspect of the upper eyelid
and skin over the lower and mesial aspects of the forehead.
Supraorbital: sensory to upper eyelid, supplies scalp as far back as the parietal bone.
o Nasociliary:
Anterior ethmoidal: branch- internal nasal: supplies the mucous membrane of the
anterior part of the nasal septum and the lateral wall of the nasal cavity.
External nasal
Infratrochlear
MAXILLARY NERVE
nd
2 branch of trigemineal nerve
Purely sensory
Leaves the cranium through foramen rotundum
Supplies:
o SKIN: Middle portion of the face, Lower eyelid, Side of the nose, Upper lip
o MUCOUS MEMBRANE: Nasopharynx, Maxillary sinus, Soft palate, Tonsil, Hard palate
o MAXILLARY TEETH & PERIODONTAL TISSUES
Branches of maxillary nerve:
Branch within the cranium:

1.
Middle meningeal nerve: SUPPLIES Dura mater in the middle cranial fossa
Branches in the pterygopalataine fossa:

1.
Zygomatic nerve
Zygomaticotemporal branch supplies skin on the side of the forehead, temple
Zygomaticofacial branch supplies skin on the zygomatic prominence of the cheek, carries,
secretary fibers from the sphenopalatine ganglion to the lacrimal gland
2.
Pterygopalataine nerve
Orbital branch- supplies periosteum of orbit
38
3.
Nasal branch-supplies mucous membrane of the superior and inferior concae, lining of the
posterior ethmoidal sinus and posterior portion of the nasal septum.
o Nasopalatine nerve: supplies palatal mucosa in the region of premaxilla.
Palatine branch- Greater (anterior) and lesser (middle and posterior) palatine nerve
Pharyngeal branch-mucous
membrane of the nasal part
of the pharynx
Posterior superior alveolar nerve

Buccal gingiva in the
maxillary molar region and
adjacent facial mucosal
surfaces.
Sensory innervation to the
alveolar bone, periodontal
ligaments and pulpal tissues
of the maxillary third,
second and first molars
(except the mesiobuccal
st
root of 1 molar)
Branch in the infraorbital canal:

1. Middle superior alveolar nerve:
Supplies:-adjacent mucosa of maxillary sinus, the two premolars & mesiobuccal root of first molar
2. Anterior superior alveolar nerve: Supplies: central incisors, lateral incisors & canine
Branch on the face (terminal branches):
1. Inferior palpebral- skin of the lower eyelid
2. Lateral nasal- Skin of the lateral side of nose
3. Superior labial- Sensory innervation of the skin and mucous membrane of the upper lip.
III.
MANDIBULAR NERVE
Largest division of trigeminal nerve
Both sensory and motor
Exits the skull through foramen ovale
Branches of the mandibular nerve:
Branches from the undivided nerve Branches of the anterior division
Nervus spinosus- supplies dura
Nerves to all muscles of
mater and mastoid air cells.
mastication except medial
Nerve to medial pterygoid
pterygoid:
Nerve to lateral pterygoid
Nerve to masseter
Nerve to temporalis
Buccal nerve: sensory to buccal
mucosa and skin of cheek
Branches of the posterior division

Auricotemporal nerve
Lingual nerve
Inferior alveolar nerve
Incisive branch
Mental nerve
Mylohyoid nerve
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.
39
If infiltration under periosteum it diffuses only to periosteum and it will be lifted up from bone causing
pain.
Methods of anesthetization: From above downwards, a) infiltration, b) field block, and c) nerve block
MAXILLARY LOCAL ANESTHESIA (NERVE SUPPLY OF UPPER JAW)
Summary of nerve supply:

o SUP alveolar N:
POST SAN: M1 M2 M3 except mesiobuccal root of M1
Middle SAN: PM1 PM2 root of M1
ANT SAN: 3 Ant teeth CI LI C
o Nasopalatine nerve: comes out thru incisive foramen
st
Supplies ANT palate till the level of start of 1 premolar.
o Greater palatine N comes thru greater palatine foramen:
o Supplies palate behind PM1
Local infiltration to anesthetize the teeth and the buccal gingiva:
40
Maxillary teeth are anesthetized by local infiltration with injection of LA into tissues surrounding
the roots of teeth and allowing solution to infiltrate the tissues to reach dental N branches that
enter the roots (done so because Sup alveolar N are not accessible).
o A needle is inserted at the reflection of alveolar and vestibular mucosa and passed along central
axis of tooth to be anesthetized.
o Needle is angled towards bony surface into soft tissue so that its tip lies opposite the periapical
region.
Nasopalatine or greater palatine block to anesthetize the palatal gingiva:
o Palatal surface also gets nerve supply from greater palatine and nasopalatine nerves so that
palatine N block is also required
o Greater palatine nerve is blocked as soon as it emerges from greater palatine foramen (between
the M2 and M3 * in the figure below) and nasopalatine nerve is blocked by injection just
posterior to incisive papilla. However, in practice LA is injected midway between palatal midline
and gingival margin of the teeth to be anesthetized to avoid unnecessary anesthetization of larger
area (e.g., see fig below, inject LA at x to anesthetize palatal gingiva of PM2 or M1).
o
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.
MANDIBULAR LOCAL ANESTHESIA (NERVE SUPPLY OF LOWER JAW)
3 nerves blocked:
o Lingual N: lingual gingiva of all the mandibular teeth
o Inferior alveolar N: all the mandibular teeth, and buccal gingiva of incisors, canines and premolars
o Long buccal N: buccal gingiva of all 3 mandibular molars
Inferior Alveolar Nerve and Lingual Nerve Block:
INF alveolar N enters the mandibular foramen and courses through mandibular canal on the medial aspect
of the ramus of the mandible forming INF dental plexus which sends branches to all mandibular teeth on
its side
Mandibular canal gives passage to INF alveolar N, artery and vein.
Another branch of the plexus, mental nerve, passes thru mental foramen and supplies skin and mucus
membrane of lower lip, skin of chin and vestibular gingiva of mandibular incisor teeth.
When this nerve block is successful all the mandibular teeth are anesthetized to median plane.
Skin and mucus membrane of lower lip, labial alveolar mucosa and gingiva and skin of chin are also
anesthetized because they are supplied by mental N, branch of inferior alveolar N.
rd
Lingual N lies 0.5cm antero-medial to INF alveolar N (sensory to ANT 2/3 of tongue, floor of mouth and
lingual gingiva) and enters mouth between medial pterygoid muscle and ramus of mandible and passes
ANT under cover of oral mucosa just inferior to M3.
41
Procedure:
o Mouth is kept wide open
o Put one finger in retromandibular space medial to which is the internal oblique line
o Needle inserted between internal oblique line and pterygomandibular raphe
o Barrel of syringe is placed in occlusal surface of opposite premolars: needle is inserted 2-2.5 cm
deep till bony resistance is encountered.
o Withdraw the needle by about 1mm and aspirate. If no blood is aspirated slowly deposit 1.25ml of
LA. This point is directly above the mandibular foramen hence inferior alveolar block is achieved
(and the mental nerve which is its branch is also blocked).
o Lingual block is ensured by withdrawing needle 0.5cm and depositing additional 0.5ml LA.
To find out if block is effective or not:
o Ask whether the lips or chin on ipsilateral side are anesthetized or not.
o Prick in gingival surface (dental probing)
Buccal Nerve block
rd
Buccal Nerve courses in the retromolar fossa, lacated disto buccal to the 3 mandibular molar between the
anterior border of the ramus and the temporal crest, to supply buccal gingiva of all the 3 molars
Procedure:
o Mouth is kept wide open.
o Insert the needle disto-buccal to the last molar and enter 2-4mm until contact with bone is made.
o Aspirate and if no blood is aspirated, deposit 0.25 ml of LA to produce buccal nerve block.
Mandibular Nerve Block:
LA injected near mandibular N where it enters infratemporal fossa

Anesthetizes auriculotemporal, INF alveolar, lingual and buccal branches of CNV3.
COMPLICATIONS OF BLOCK: (@ PANT)
Trismus
Transient facial nerve Paralysis
Allergic reaction
Needle break
42
TOOTH EXTRACTION
Definition: Exodontia or tooth extraction is defined as painless, atraumatic removal of tooth from its investing
structures.
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
1.
2.
3.
4.
5.
Cardiac disease
a. Valvular heart disease.
b. RHD
c. IHD
d. CHF
e. HTN
f. Patient on Anticoagulants
Blood Diseases
a. Severe anemia
b. Leukemia
c. Hemophilia
d. Agranulocytosis
Addisons Disease
Patients on Corticosteroids (Require dose
adjustment)
Jaundice and Liver Disease
a. Vitamin K Deficiency
b. Blood Clotting Factors
c. Prothrombin
d. Fibrinogen Deficiency
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Diabetes Mellitus (Healing delayed)

Thyrotoxicosis
Pregnancy during first and second trimester
a. Abortion and Premature Delivery
b. Gravid uterus uncomfortable
c. Less Stamina for opening mouth
Very Old Age
Epileptic patients
Presence of fever
Debilitating diseases
a. TB
b. Cor pulmonale
c. Asthma
d. Nephritis
Psychosis
Neurosis
Allergy to LA
Incorporative patients
During Menstruation
Local Contraindications
1.
Any acute infections like

a. Acute gingivitis
b. Acute periodontitis
c. Acute pericoronitis
d. Acute cellulitis
43
2.
3.
e. Acute osteomyelitis
Malignancy
Irradiated Jaw: Acute osteoradio necrosis can occur due to end-arteritis obliterants
Absolute Contraindications
1.
2.
Hemangioma
AV malformation ( because bleeding that cannot be stopped)
(If such condition occurs put teeth on socket and press)
Relative Contraindications: all other contraindications
INSTRUMENTS (LAST CHAPTER FOR PHOTOS)
Straight Elevator
Root Elevator
Lower molar and premolar forceps: They have wide gap that does not meet. Same for right and left
Lower anterior teeth forceps: Small gap where ends meet
Upper right molar and premolar forceps: Elevated edge on tip of forceps on left side
Upper left molar and premolar forceps: Elevated edge on tip of forceps on right side
Upper anterior teeth forceps
PROCEDURE
1.
2.
Give Local Anesthesia

After sensation is obtunded extract tooth by mobilizing root and extracting with forceps
POST EXTRACTION INSTRUCTIONS
White Cotton Pad or Gauze for 30 minutes (it takes 20 to 25 mins for fibrin mesh to form)
Dos
Rest
Take prescribed medicines
Soft, lukewarm or cold food: Causes vasoconstriction
Cold compression with ice pack from outside: With pack from outside it
decreases surgical edema
Warm saline mouthwash from next day for two to three days, two to
three times a day.
If any bleeding, pain, or complaint, contact hospital
Donts
Do not spit or rinse as far
as possible: Clot might get
dislodged
Do not take hot food or
drink for 24 hours.
Do not take caffeine:
Causes vasodilatation
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
44
TOOTH FILLING
Temporary or permanent.
CHARACTERISTICS OF GOOD CEMENT
During application:
o Easy preparation
o Easy to manipulate
o Fast setting
Physical characters:
o Good attachment
o Color matching with teeth
o Hard
o Not undergoing corrosion
o Coefficient of thermal expansion equal to teeth
SOME FILLINGS
Restorative material
1. Miracle mix
Silver and glass ionomer cement (GIC)
Silver amalgam: hard but not sticky
GIC: Sticky but not hard
Takes 2 hr to set, therefore do not allow to drink for 2 hrs, use waterproof
cream to prevent from action of saliva
2. Silver amalgam filling
3. GIC filling
4. Composite filling: Light and strong and good color match
Cements (Temporary)
ZOE (Zinc oxide eugenol)
Zinc phosphate
Zinc polycarboxylate
Silicate
Silicophosphate
STEPS
1.
2.
3.
4.
5.
6.
Acid etch applied on surface of enamel

34% orthophosphonic acid
Dematerializes surface of tooth creating pores
After few seconds, wash.
There will be a dull chalky white discoloration
Bonding liquid (organic monomer) added
Flows into the pores formed by etching and fills the pores
Composite material added over this
Light (intense blue visible light) passed
Polymerizes organic monomer and sets the composite material
After filling patient is asked to bite so that any extra filling material is removed and material fits the shape
of teeth
THERE ARE TWO TYPES OF COMPOSITE:
Light cure composite which requires light for setting (Light source used is halogen).
Self-cure composite: Sets on its own, but disadvantage is that while working in high room temperature,
sets before finishing the filling
45
PULP CAPPING
Capping done when pulp is closed, or near exposure, already exposed in order to save pulp from infection
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
46
ROOT CANAL TREATMENT

INDICATIONS:
Non-vital teeth
Irreversible pulpitis (When pulp cavity is exposed >1mm with infection and pain or when the pulp is
necrosed and irreversibly destroyed with infection)
Periapical periodontitis
Periapical abscess
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
INSTRUMENTS USED IN RCT (LAST CHAPTER FOR PHOTOS)
Files
Burr
Reamers
Brouch: spikes present
GP points (gutta perhca points): (absorbent point papers) Absorbs pulp cavity contents
POST AND CORE
Indications: Root intact but crown damaged either due to trauma or caries
Procedure:
o Extirpation of radicular pulp and sealing of the apical foramen using gutta-percha
o A post is placed in the radicular pulp cavity
o Then a core is placed on top of the post on the remains of the crown
o Finally a prosthetic crown is placed on top of the core
47
MAXILLOFACIAL INJURIES
CLASSIFICATION
Maxillofacial injuries have been classified into three parts:
Upper third (roughly above the eyebrows)

Middle third (above the mouth): An area bounded superiorly a line drawn across the skull from Z-F suture,
across F-N suture to Z-F suture on opposite side; inferiorly the occlusal plane and posteriorly as far as the
frontal bone above and the body of sphenoid below, and the pterygoid plates of the sphenoid
Lower third (the mandible)
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 MANAGEMENT
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 MANAGEMENT
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 to 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
Inexpensive
Short procedure/limited operating time
Generally easy, no great operative skill
required
Biologically conservative, no need for
surgical tissue damage
No foreign body/material in the body
DISADVANTAGES
Cannot obtain absolute stability
No compliance from the patient due to long period of
fixation
Loss of patient to follow up
Difficult nutrition
Complete maintenance of oral hygiene not possible
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
48
MANDIBULAR FRACTURES
ETIOLOGY
Assault: 55%
Fall 21%
RTA 15%
Sports 4%
Industries 3%
CLASSIFICATION
American system of classification
(according to type of fracture)
Simple
Compound
Communicated
Open / Close
Pathological fracture
Undisplaced / Displaced
According to cause
Favorable vs. unfavorable fracture
Direct violence
Indirect violence
Excessive muscle contraction
Favorable fracture: vertically

and horizontally undisplaced
Unfavorable fracture: vertically
and horizontally displaced
According to site of fracture: (most commonly used)

o Condyle
o Coronoid
o Ramus
rd
o 3 molar and Angle
o Body:
Molar
Mental
Cuspid or canine
o Symphysis (parasymphysis)
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
RADIOLOGICAL EVALUATION
Paranomic view (unobstructed clear view), orthopantamogram (OPG) commonly done

Townes 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
MANAGEMENT OF MANDIBULAR FRACTURE

Aims:
Anatomic reduction of fracture
Stabilization of fracture
Preservation of cranial nerve function
Functional rehabilitation
49
Approach:
MMF is secured initially
Then based on different factors, choice is made between: (indications for closed and open reduction)
Closed reduction (i.e. only MMF)
Non-displaced angle fracture (tooth in proximal
segment)
Ramus fracture
Non-displaced symphysis fracture(mobile body)
Non or minimally displaced high condyle fracture
Intracapsular condyle fracture
Open reduction with rigid or non-rigid fixation

Non-displaced vertically modified
symphysis/body
Displaced angle fractures
Condylar occlusion
B/L severe condylar displacement with
comminuted mid face fracture
Duration of immobilization with MMF:

o Teen/adults: 5-7 weeks
o Children: 4-6 weeks
o Infants- 2-3 weeks
Favorable fracture: simple fixation is employed
Unfavorable fracture: prolonged fixture is employed
Antibiotic prophylaxis to patient with h/o RHD (no longer recommended according to NICE guidelineKumar and Clarke for further information)
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
Indications for open reduction with non-rigid fixation and MMF:
Occlusal discrepancy
Associated alveolar fracture
ADVANTAGES AND DISADVANTAGES OF OPEN REDUCTION WITHOUT MMF (i.e. with rigid 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
Early return to normal jaw function, normal nutrition,
normal oral hygiene and avoidance of airway problems
Can get absolute stability, promotes primary bone healing
Bone fragments re-approximated with direct visualization
Avoids MMF for patients with occupational benefits,
seizures, potential airway problems, psychiatric disorders
DISADVANTAGES
Need for an open procedure
Significant operating time and great skill
required
Expensive
Risk of neurovascular damage
Scarring
MANDIBULAR CONDYLAR FRACTURE
If the condyle is avulsed : open reduction

If the fracture is intra-capsular: closed reduction and occlusal range of movement exercised
In a growing child: immobilize the fracture site early
In edentulous fracture : liquid diet, minimal displacement minimal pain
EDENTULOUS MANDIBULAR FRACTURE
Avoidance of mandible-maxillary fixation ( MMF)

Rigid internal and skeletal fixation
6wks mobilization
Bone grafting (if severe atrophy has occurred)
50
Condylar fixation
COMPLICATIONS OF MANDIBULAR FRACTURE
Infection
Delayed union
Malunion
Malocclusion
TMJ problems
If complications occur the whole management procedure will have to be repeated, and mandibular
fracture immediately reduced
Indications for tooth extraction: (infection can lead to malunion)
o Tooth fracture
o Grossly mobile
o Excessive tooth exposure
o Infection has occurred
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 procedures)
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:
Advised to maintain good oral hygiene
Told how to recognize signs of infective endocarditis and advised when to seek expert advice.
Antibiotics prophylaxis for dental procedure in patients with Infective Endocarditis:

Situation
Agent
Oral
Unable to take oral medication
Amoxicillin
Ampicillin
Cefazolin or ceftriaxone
Adults
2g
2 g IM/ IV
1 g IM/IV
Allergic to penicillins or ampicillin

Oral
Cephalexin
2g
Clindamycin
600 mg
Azithromycin /clarithromycin
500 mg
Unable to take oral medication Cefazolin or ceftriaxone
1 g IM/IV
Clindamycin
600 mg IM/IV
All regimen are single dose to be given 30 to 60 minutes before procedure
Regimen
Children
50 mg/kg
50 mg/kg IM/IV
50 mg/kg IM/IV
50 mg/kg
20 mg/kg
15 mg/kg
50 mg/kg IM/IV
20 mg/kg IM/IV
51
MAXILLARY FRACTURES
FRACTURE OF MIDDLE THIRD OF THE FACE

Middle third of the face consists of following structures:
Two maxillae
Two zygomatic bones
Two zygomatic process of the temporal bones
Two palatine bones
Two nasal bone
The vomer
The ethmoid and its attached conchae
Two inferior conchae
The pterygoid plates of the sphenoid
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
Guriens sign: Ecchymosis in greater palatine foramen
(low level fracture)
Often associated with midline split in the palate
Mobility of the teeth bearing segment of maxilla
Slight swelling of the upper lip
Ecchymosis present in the buccal sulcus Derangement of occlusion
beneath the zygomatic arch
Gagging of occlused (ANT open bite) as maxilla falls
down posterior teeth clutches so ant mouth remains
Ecchymosis in upper vestibule
open causing lengthening of face
LEFORT II AND III FRACTURES
Lefort II fracture
Lefort III fracture
Introduction
Pyramidal fracture
Starts at or just below naso-frontal
suture,
extends
inferolaterally
through lacrimal bones and inferior
orbital floor and rim, through or near
the infraorbital foramen, through
anterior wall of maxillary sinus and
below Zygomatic buttress and
through the pterygoid plates
Clinical features:
Step deformity at infra-orbital margin
Mobility of midface detectable at
nasal bridge and infra-orbital margins
Introduction
Cranio-facial disjunction (causes elongated face)
It is a high fracture that starts at nasofrontal &
frontomaxillary suture and extends across the floor of orbit
along inferior orbital fissure and continues along lateral
orbital rim
Extends posteriorly along the nasolacrimal groove to involve
the ethmoid, but spares the strong sphenoid
Extends inferiorly along perpendicular plate of ethmoid to
vomer and through the pterygoid plates
Clinical features:
Tenderness and separation at frontozygomatic sutures
Tenderness and deformity of zygomatic arches
Lengthening of face
52
Anesthesia or parasthesia of cheek

Possible diplopia
Pupil tend to be level unless there is
gross unilateral enophthalmos
Nasal bones move with midface as a
whole but often otherwise intact
Depression of ocular levels

Enophthalmos
Hooding of eyes
Lengthening and sometimes extreme disorganization of
nasal skeleton
Often profuse CSF rhinorrhoea
Tilting of the occlusal plane with gagging on one side only
Lateral displacement of midline of upper jaw
Mobility of whole face as a single block
Clinical features common to both Lefort II and III:

Gross edema of the face
Characteristic moon face appearance
Circumorbital ecchymosis
Subconjuctival hemorrhage
Limitation of ocular movement with possible diplopia
and enophthalmos
Bleeding from the nose and CSF rhinorrhea
Cribriform fracture: CSF rhinorrhoea: tram like effect:
salty taste
Dish-face deformity of the face with occasional
lengthening of the face
Retroposition of maxillae, so that anterior teeth do not
meet, and there is gagging on the posterior teeth
Difficulty in opening mouth, and sometimes

inability to move the lower jaw
Mobility of upper jaw
Haematoma of the palate
Cracked pot sound on tapping the teeth
Telecanthus: widening of medial anthus :
globe is attached laterally to the bone by a
suspensory ligament of locaud if fracture
occurs above the attachment: eye drops
down: diplopia
Enophthalmous: fracture in orbital rim
INF orbital rim fracture: entrapment of
inferior rectus: difficulty in upward gaze
RADIOGRAPHIC VIEW
Occipitomental view/PNS view , lateral view, Occlusal view, fronto-occipital view, CT scan
MANAGEMENT:
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)
Internal fixation: direct and indirect osteosynthesis

Direct osteosynthesis
Internal wire suspension
Transosseous wiring
Frontal-central or lateral
Miniplates
Circumzygomatic
Tranfixation with K-wire
Pyriform aperture
External fixation
Craniomandibular
o Halo frame
o Box frame
Craniomaxillary halo frame
Suspension from the cranial vault
COMPLICATIONS
IMMEDIATE COMPLICATIONS
Airway
Nasal hemorrhage
Ophthalmic
Cerebral
Inaccurate reduction
Insecure fixation
LATE COMPLICATIONS
Complications arising from head injuries
Complications arising from fracture
Bony deformity
Lacrimal system
Ophthalmic
neurological
Non-union
53
ORAL CANCER
Quite common in SE Asia

Usually arises in parts of oral mucosa
Oral ca constitutes of about 1% of all malignancies but erosive LP makes up to 50% DESTRCUTIVE ORAL
LESION
95% OF AL ORAL CA ARE SQ CELL CA, 5% SARCOMAS
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:
DX:
All oral cancer appear as white red ulcers

Neck nodes spread: poor prognosis
FNAC
Biopsy: most reliable
Toluidine blue staining
Imaging CT scan
SQUAMOUS CELL CARCINOMA
HISTOLOGY:
o Marked cellular pleomorphism
o Loss of polarity
o Hyperchromatic nuclei, variable in size, shape and number
o Abnormal mitotic figures
o BM intact or invaded
PROGNOSIS:
o If localized at the time of Dx : survival rate: 75%
o If regionalized: survival rate: 50%
o In distant metastasis: survival rate: 18%
RISK
o Is more among males and after 49 yrs
o Smokers, tobacco chewers, betel nut chewers have increased risk
o Heavy alcohol consumers and always at increased risk
C/F
o symptomatic growth
o mucosal discoloration
o pain and non-healing ulcer
o constitutional symptoms
TREATMENT:
o chemotherapy alone
o radiotherapy alone
54
surgery:
radical resection
palliative surgery
removal of tumor
o relief of pain and anxiety
o rehabilitation and follow up
Toluidine blue staining:
o it recognizes epithelial dysplasia and oral cancers
o thus aids in DX
o stain binds to cells with increased DNA synthesis
o stain binds to sulphated mucopolysaccharides
o by the staining it points out the accurate site for biopsy
Lateral border of tongue is the most common site of ca
o
MALIGNANT 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
PREMALIGNANT LESION OF ORAL CAVITY

Common premalignant conditions include:
Leukoplakia: 6% has chance of malignant transformation
Chronic hyperplasic candidiasis (50%)
LP (1%)
Sub mucus fibrosis (0.2%)
Erythroplakia (50%)
Sublingual keratosis (erosive LP) 50%
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
LOCALLY INVASIVE TUMOURS OF JAW
Amenoblastoma
Adenoid cystic ca
Pleomorphic adenoma
55
CYSTS OF OROFACIAL REGION
Definition (Kramer, 1974): Pathological cavity containing fluid, semi-fluid, gas but not pus; frequently but
not always lined by epithelium.
Cyst is a cavity occurring in hard or soft tissues with a liquid or semi-solid or air only
It is surrounded by a definitive connective tissue wall or capsule with/without the epithelial lining
1. Odontogenic
Keratinizing
Primordial
cyst/Keratocyst
Extrafollicular
dentigerous cyst
2. Non-odontogenic
Non-keratinizing
Periodontal cyst
o Lateral
o Apical
o Residual
Dentigerous cyst
Eruption cyst
Nasopalatine cyst
Nasoalveolar cyst
Globulomaxillary cyst
Median palatine cyst
3. Bone cyst
Solitary bone cyst
Stafnes idiopathic bone cyst
Aneurysmal bone 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 wont 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
56
Treatment
Enucleation: Do not recur after complete enucleation OR
Marsupialization: Indications of marsupialization:
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
57
INSTRUMENTS
PERIOSTEAL ELEVATOR
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 (and 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 are deep-seated.
58
2.
Angled root elevator: In these sets of elevators, the handles are in line with the shank, but the working
ends are set at an angle. The picture here is of the Cryer root elevator, whose sharp working tip makes an
obtuse angle with the shank. These are used to either lift the root or move a large root fragment.
TOOTH EXTRACTION FORCEPS

There are several types of tooth extracting forceps. They can be divided into following parts:
A beaks
A neck and
Handles
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 Cshaped forceps are used for mandibular teeth.
Maxillary incisors and canine forceps: (Forceps # 1)
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.
59
Maxillary Premolars
These are Z-shaped and when closed resemble the Bayonet (the blade at the tip of the muzzle of a rifle).
Therefore, these are also called the Bayonet. The size of the beak varies to accommodate different sizes of the
maxillary premolars, some have wide beak while others have long and slender beaks. The forceps #65 which is
a kind of maxillary premolars, is also called universal maxillary premolars, and can be used for all types of
maxillary teeth. The thin, slender forceps can also be used for extracting root fragments and are also called root
forceps.
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.
60
Right sided maxillary molar forceps
Rigth and left maxillary molar forceps
61
Mandibular Incisor, Canine and Premolars Forceps
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 pointed.
Mandibular Molar Forceps
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.
62
DENTAL SPATULA
Cement spatula is used to mix and handle cements and is not used in the mouth. Stainless steel spatulas are
used to mix various dental cements, but not with silicate cements (plastic spatulas should be used for silicate
cements).
WAX SPATULAS
These spatulas are heated and then used for handling of wax.
CEMENT PLACING AND PLUGGING INSTRUMENT
The flattened end is used for transporting the cement while the flat-topped, rounded end is used for plugging
the cement in the prepared cavity.
63
BALL BURNISHER
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.
64
EXPLORERS
Pigtail explorer
Periodontal probe and pigtail explorer
65
Explorers are sharp, pointed instruments for reaching the various surfaces of teeth conveniently. These
instruments are used for diagnostic purposes based on the tactile sensation and on mechanical penetration of
defects in tooth surfaces. Some of their functions are:
a. Locating caries and other defects on various surfaces of the teeth ("the catch is diagnostic of caries)
b. Locating subgingival calculus
c. Locating of faulty margins on dental restorations
PERIODENTIAL PROBES (look at the pigtail explorer for the picture)
These are non-cutting instruments with blunted working ends. They are used to measure the depth of the
periodontial sulcus or pockets and are therefore provided with marking for measurement.
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.
DENTAL MIRRORS OR ODONTOSCOPE
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).
66
RCT FINGER SPREADERS
They are used to mobilize the cones for achieving tight seal of the cones. For example, at first a master cone is
inserted and then finger spreader of suitable size is inserted into the root canal and then the master cone is
pressed to achieve tight seal and also to create space for accessory cones. Then the spreader is withdrawn and
a suitable sized gutta-percha cone is inserted in its place. The process is continued until a tight seal is achieved.
GUTTA-PERCHA POINTS
Gutta-percha points are made from the refined,
coagulated, milky exudate of trees in the Malay
peninsula. Gutta-percha is pink or gray in color. It is
softened by heat and is easily molded. When cool,
gutta-percha maintains its shape. Gutta-percha
points are used as a root canal filling material.
Its major advantages are:
a. They have a high thermal expansion.
b. They do not shrink unless used with
solvent
c. They are radiopaque, conduct heat poorly,
and are easy to remove from the root
canal
d. They may be kept sterile in antiseptic
solution, are impervious to moisture, and
are bacteriostatic (prevent the growth or
multiplication of bacteria)
The major disadvantages are:
a. They shrink when used with a solvent
b. They are not always easy to introduce into the root canal
67

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Dental notes

A complete note for the final year MBBS

Dental Notes by Sadichhya, Shooga & Sumesh

Middle third fracture

Hypersensitive tooth: pulpitis

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Functions of the Oral Cavity

Dental Notes by Sadichhya & Shooga

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STAGES OF TOOTH DEVELOPMENT

Invagination of dental bud by the mesenchyme

Dental Notes by Sadichhya, Shooga & Sumesh

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Dental Notes by Sadichhya & Shooga

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Mastication: cutting, piercing, grinding

OCCLUSAL LINE, MESIAL LINE AND THE FOUR QUADRANTS

ANTERIOR AND POSTERIOR TEETH

Demarcation line: junction of lips and cheek

Mesial surface: Towards the midline along the arch

Maxillary/ upper arch

Dental Notes by Sadichhya, Shooga & Sumesh

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Period of primary/ deciduous dentition: 6mth-6yrs

Primary Dentition (Temporary Teeth)

Secondary Dentition (Permanent teeth)

ERUPTION DATES OF DENTITION (THESE ARE ACCORDING TO CLASS PRESENTATION)

Dental Notes by Sadichhya & Shooga

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INTERNAL STRUCTURE OF TOOTH

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o Root canal in root: contains radicular pulp

Dental Notes by Sadichhya & Shooga

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Dental Notes by Sadichhya, Shooga & Sumesh

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CLINICAL DENTAL NOTATION

Hungarian dentist Adolf Zsigmondy

Used in Nepal, but cant be entered in computer

FDI (FDRATION DENTAIRE INTERNATIONALE)/ WORLD DENTAL FEDERATION NOTATION

Used two numbers to denote each tooth.

The second number denotes the number of the tooth:

Thus, the deciduous dentition will have the following notation:

UNIVERSAL NUMBERING SYSTEM

Dental Notes by Sadichhya & Shooga

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Status of oral hygiene judged by inspection of oral cavity for:

REQUIREMENTS OF A TOOTH BRUSH

REQUISITES FOR SATISFACTORY BRUSHING

Should clean all dental surfaces including gingival crevices

Dental Notes by Sadichhya, Shooga & Sumesh

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Any technique is effective only if it can completely remove the plaque

There are certain factors which determine the frequency of brushing:

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Any liquid, paste or powder used to clean teeth

CHEMICAL CLEANING OF TEETH

Removes both supra and sub gingival calculi

Dental Notes by Sadichhya, Shooga & Sumesh

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Dental Notes by Sadichhya & Shooga

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The process of plaque formation can be divided into 3 stages: