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A Concise Textbook of Oral
and Maxillofacial Surgery
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A Concise Textbook of Oral
and Maxillofacial Surgery
Author
Sumit Sanghai BDS (RGUHS)
Lecturer
Dr BR Ambedkar Institute of Dental Sciences and Hospital
Patna, India
Co-Author
Parama Chatterjee BDS (RGUHS)
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A Concise Textbook of Oral and Maxillofacial Surgery
2009, Sumit Sanghai, Parama Chatterjee
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by
any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the authors
and the publisher.
This book has been published in good faith that the material provided by authors is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and authors will not be held responsible for any inadvertent error(s). In case
of any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition: 2009

ISBN 978-81-8448-505-9
Typeset at JPBMP typesetting unit

Printed at Rajkamal
Dedicated to
My father Mr Satyanarayan Sanghai
and my mother Mrs Sassi Sanghai,
for their continuous encouragement,
understanding and support
Foreword
It is with great pleasure that I write this foreword for Dr Sumit Sanghai, an undergraduate student
of mine who has done a commendable job of writing this book. A comprehensive coverage of
the subject based on the syllabus of DCI along with a lucid representation makes it a valuable
aid to BDS students in the subject of Oral and Maxillofacial Surgery. It is a concise compilation
with self explanatory diagrams and well laid out tables. He has explained the subject in simple
sentence structuring making it easier to comprehend the concepts, facts and procedures. The
attractive outlay and organized presentation makes easy reading.
I wish him all the best, God Bless.
Ramdas Balakrishna
BDS, MDS
Oral and Maxillofacial Surgeon and Implantologist,
ProfOxford Dental College and Hospital, Bangalore
Foreword
The efforts that have gone into the compilation of this text is commendable. I congradulate these
two young doctor, Dr Sumit Sanghai and Dr Parama Chatterjee for being a source of inspiration
to numerous impressionable minds.
Deepika Kenkere
BDS, MDS, FICOI, MAOMSI, MIAO
Oral and Maxillofacial Surgeon and Implantologist
Prof. and Head-Department of Oral and Maxillofacial Surgery
Sri Rajiv Gandhi College of Dental Sciences and Hospital, Bangalore
FOREWORD
I wholeheartedly congratulate Dr Sumit Sanghai on his endeavour to bring out this edition of
Concise Textbook of Oral and Maxillofacial Surgery. Oral surgical procedures have been ingrained
deeply into every sophisticated dental practice. This text fulfils the need for a concise and
comprehensive book for the dental graduates. The uniqueness of this book lies in the sequential
manner in which the chapters have been dealt with. I am sure that this edition will prove to
be a valuable source of information for all dental graduates.
Arun Jacob Silas

BDS, MDS
Principal
Prof. and Head-Department of Pediatric Dentistry
FOREWORD
I wholeheartedly congratulate Dr Sumit Sanghai for his sincere effort and hard work to bring
out this edition of A Concise Textbook of Oral and Maxillofacial Surgery. I am sure this book
shall be of a great help for all the dental students and graduates.
I wish him All the Best.
Uttam K Sen
BDS, MDS (Cal)
Principal
Prof. and Head-Department of Prosthodontic Dentistry
Dr. N. Srinath B.D.S., M.D.S., FDSRCS (Eng)
Consultant Oral & Maxillofacial Surgeon, Bangalore
Prof. Krishna Devaraya College of Dental Sciences and Hospital, Bangalore
FOREWORD
I whole heartedly congratulate, Dr Sumit Sanghai and Dr Parama Chatterjee for their sincere
efforts to take out this edition of A Concise Textbook of Oral and Maxillofacial Surgery. I foreword
this book to all the young dental students, dental graduates and the dental fraternity. This book
provides an academic excellence in the field of oral and maxillofacial surgery, with extensive point
wise coverage of subject in an easy and lucid language.
I wish them All the very best for this new endeavour.
N Srinath
BDS, MDS, FDSRCS (Eng)
Comments
This simple and comprehensive Textbook on Oral and Maxillofacial Surgery put forward by
Dr Sumit Sanghai and Dr Parama Chatterjee of my college is an ideal referral book for the dental
undergraduates and also for general dentists in their day to day practice.
I wish them the best.
Roy Thomas
BDS, MDS
Prof.-Department of Oral and Maxillofacial Surgery
Comments
I congratulate Dr Sumit Sanghai and Dr Parama Chatterjee for their endeavour. This book is
concise but has a good coverage of all the topics necessary for the BDS student.
I wish them success.
Rajarshi Banerjee
BDS, MDS, MOMS, RCPS
Oral and Maxillofacial Surgeon
Prof. and Head-Department of Oral and Maxillofacial Surgery
Dr BR Ambedkar Institute of Dental Sciences and Hospital, Patna
xiv A Concise Textbook of Oral and Maxillofacial Surgery
Comments
I congratulate Dr Sumit Sanghai and Dr Parama Chatterjee for taking such a huge step, it is
indeed appreciable for the young sprouting doctors for taking such pain at this age to author
a book like this. This textbook is truly concise and very helpful for the undergraduate students.
GC Veena
BDS, MDS
Department of Oral and Maxillofacial Surgery
Comments
I heartily congratulate Dr Sumit Sanghai and Parama Chatterjee for taking such a huge step.
It is appreciable that they took such pain to author a book like this. The subject is truly very
precise, the illustrations are clear and the whole text has been presented in a concise manner
which should be very useful for undergraduate students. I wish them All the Best.
Jayashree D
BDS, MDS
Department of Oral and Maxillofacial Surgery
Preface
TIME has become a very important factor in todays education system in India. Students get
a very scarce amount of time to even go through the various textbooks available and required
for writing their examination in full confidence. We have tried to compile all the required information
in one single text and in a concise manner so that the student can be confident to write his/
her theory examination and viva-voce. This text has a number of tables which would help further
revisions and easy learning. It has numerous diagrams that are all handdrawn so that the student
can get a better understanding of the subject and can easily replicate it in his/her examination
for better presentation. The coloured pictures even further enhance the understanding of the
subject. For enthusiastic students we have added a list of reference at the end of each chapter
as due to the concise format of the book, we have not included every minute details which are
of less importance for undergraduate exam going students.
Sumit Sanghai
drsumitsanghai@gmail.com
Parama Chatterjee
drparamachatterjee@yahoo.com
Acknowledgements
We thank you LORD for giving us the strength and power to write this book.
We would like to thank our parents, Mr SN Sanghai, Mrs S Sanghai and Dr J Chatterji, Dr I
Chatterji, our sister Mrs Gunjan Goel and our brother, Janak Chatterji, for their continuous support,
help and encouragement.
We express our heart-felt appreciation to Dr Ramdas Balakrishna MDS, Department of Oral and
Maxillofacial Surgery, Oxford Dental College and Hospital, Bangalore for taking out his precious time
for helping us in proof-reading the text. We solicit our special thanks to Dr Arun Jacob MDS, Prof. and
Head-Department of Pedodontics, Principal, Sri Rajiv Gandhi College of Dental Sciences and Hospital,
Bangalore; Dr Deepika Kenkere MDS, Prof and Head-Department of Oral and Maxillofacial Surgery,
Sri Rajiv Gandhi College of Dental Sciences and Hospital, Bangalore and Dr N Srinath MDS,
Department of Oral and Maxillofacial Surgery, Krishnadenaraya College of Dental Sciences and
Hospital, Bangalore for taking out their precious time among their busy schedule in providing us the
required help, support and encouragement.
We express our deepest thanks to our teachers, Dr Roy MDS, Dr Rajnikanth MDS, Dr GC Veena
MDS, Dr Jayashree D MDS, Dr Maqsood MDS, Department of Oral and Maxillofacial Surgery, Sri Rajiv
Gandhi College of Dental Sciences and Hospital, Bangalore; Dr Tejawathi Nagaraj MDS, PRof. and
Head-Department of Oral Medicine and Radiology, Sri Rajiv Gandhi College of Dental Sciences and
Hospital, Bangalore; Dr Vaibhavi Joshipura MDS, Prof and Head, Dr K Vijay MDS, Dr Umesh MDS,
Department of Periodontics, Sri Rajiv Gandhi College of Dental Sciences and Hospital, Bangalore; Dr
Vipool Malkan MDS, Prof and Head, Dr Srinidhi MDS, Department of Conservative Dentistry and
Endodontics, Sri Rajiv Gandhi College of Dental Sciences and Hospital, Bangalore; Dr Geeta Patil
MDS, Prof and Head, Dr Mohammed Saleem MDS, Department of Prosthodontics, Sri Rajiv Gandhi
College of Dental Sciences and Hospital, Bangalore; Dr Tilakrani MDS, Prof and Head, Dr Sreedevi
MDS, Dr Dinesh Reddy MDS, Department of Orthodontics, Sri Rajiv Gandhi College of Dental Sciences
and Hospital, Bangalore; Dr Yellappa MDS, Prof and Head-Department of Preventive and Social
Dentistry, Sri Rajiv Gandhi College of Dental Sciences and Hospital, Bangalore; Dr Yogesh MDS, Prof
and Head-Department of Oral Pathology, Sri Rajiv Gandhi College of Dental Sciences and Hospital,
Bangalore; Dr Jaiprakash R Prof and Head-Department of Pharmacology, Sri Rajiv Gandhi College of
Dental Sciences and Hospital, Bangalore; Dr R Banerjee MDS, Department of Oral and Maxillofacial
Surgery, Dr BR Ambedkar Institute of Dental Sciences and Hospital, Patna; Dr MK Bakshi MDS,
Department of Pedodontics, Dr BR Ambedkar Institute of Dental Sciences and Hospital, Patna; Dr
Uttam Sen MDS, Prof and Head-Department of Prosthodontics, Principal Dr BR Ambedkar Institute of
Dental Sciences and Hospital, Patna; Dr Ashok BDS, Dr Raghavendra BDS, Dr Arundhati BDS, Dr
Shalini BDS, Dr Faiz Ahmed MBBS, Sri Rajiv Gandhi College of Dental Sciences and Hospital,
Bangalore; Dr OP Chowdhury BDS, Dr BR Ambedkar Institute of Dental Sciences and Hospital, Patna
for their excellent teaching and guidance.
xviii A Concise Textbook of Oral and Maxillofacial Surgery
We owe thanks to our friends and collegues, Dr Sreevidya PD, Dr Pushkar Kumar, Dr Abhishek
Suryavanshi, Dr Rohit Agarwal, Dr Lalith Kumar Goel, Dr Gitanjali Das, Dr Preeti K, Dr Jasmine Kaur
Sohal, Dr Krishna Kumar, Dr Rishi Gupta, Dr Vikas Berwal, Dr Mandakini AL, for their help, support
and encouragement right from the beginning till the end of my writing.
We are thankful to our juniors, Prashanth and Monalisa for their help in completing the book.
We particularly thanks, Mr T Sounthar MLIS, MPhil, Chief Librarian, Sri Rajiv Gandhi College of
Dental Sciences and Hospital, Bangalore for allowing us to enrich our knowledge by providing the
required books and journals and also in preparing the soft copy of the book.
Lastly we would like to thank Mr Tarun Duneja, Director (Publishing), Jaypee Medical Publisher
(P) Ltd, New Delhi for accepting our text for publication.
Sumit Sanghai Parama Chatterjee
Contents
UNIT I: INTRODUCTION
1. Introduction to Oral and Maxillofacial Surgery 3
2. Diagnosis in Oral and Maxillofacial Surgery 5
3. Management of Medically Compromised Patients
and Medical Emergencies 18
4. Sterilization and Infection Control 40
5. Armamentarium and their Usage in Oral and Maxillofacial Surgery 45
UNIT II: ANESTHESIA

6. Anesthesia in Oral and Maxillofacial Surgery 67
UNIT III: EXODONTIA

7. Exodontia 91
8. Impaction 106
UNIT IV: MINOR ORAL SURGERY

9. Infection of the Orofacial Region 119
10. Inflammatory Disease of Jaw Bone 137
11. Surgical Procedures in ProsthodonticsPreprosthetic Surgery 147
12. Surgical Procedures in EndodonticsEndodontic Surgery 165
13. Maxillary Sinus and Its Disorders 171
14. Cysts of the Oral Cavity 179
15. Tumors of the Oral Cavity and Oral Malignancies 186
16. Salivary Gland and Its Disorders 193
17. Temporomandibular Joint Disorders 201
xx A Concise Textbook of Oral and Maxillofacial Surgery
18. Surgical Procedures in OrthodonticsOrthodontic Surgery 215

19. Neurogenic Disorders of Maxillofacial Region 230
20. Fractures of the Jaw 235
UNIT V: APPENDICES
Appendix - 1: Osteology 261
Appendix - 2: Case History 265
Appendix - 3: Armamentarium 266
Appendix - 4: Facial Pain 268
Appendix - 5: Facial Swelling 270
Appendix - 6: White Lesions 271
Appendix - 7: Inability to Open Mouth 272
Appendix - 8: Healing of Wound 273
Appendix - 9: Extraoral Injections 274
Appendix - 10: Cryosurgery, Laser Surgery and Electrosurgery 276
Index 279
UNIT I
INTRODUCTION
Introduction to Oral
and Maxillofacial 1
Surgery
DEFINITION is done to gain adequate access to the

Oral and maxillofacial surgery is a branch of surgical site.
Dentistry that deals with the art, diagnosis and ii. Cutting bone: Burs, Chisels, Gouges,
treatment of various diseases, pathologies and Rongeurs and files are used to cut and
defects involving the orofacial region. remove bone for gaining adequate
access.
PRINCIPLES OF SURGERY iii. Retraction: Retraction of the tissue layers
The practice of surgery rests on certain divided by the incision and dissection is
fundamental principles which have to modify done to gain adequate access and
the technique to suit the anatomical field, the protect tissues.
type of operation and the conditions obtaining iv. Cleaning the field of operation: Fluid
at the time. and loose debris must be cleaned from
1. Principles of painless surgery: Anesthesia is the field of operation by using dry
indicated before any surgical procedure to gauge, cotton or suction.
avoid psychological and physical stress to 5. Principles of arrest of hemorrhage:
the patient. Hemorrhage can be arrested by following
2. Principles of asepsis: It is the exclusion of methods:
micro-organism from operative field to i. Digital pressure
prevent them from entering the wound. ii. Hemostats or artery forceps
Proper preoperative and operative care iii. Ligatures
should be taken to achieve proper asepsis. iv. Packing
3. Principles of minimal damage: Certain v. Posture
radical operations may regrettably require vi. Electrocoagulation
the sacrifice of vital structure but this does vii. Placing hot packs and bone wax over
not often apply in oral surgery. bleeding bone
4. Principles of adequate access: This is 6. Principles of debridement (toilet of wound):
achieved by the following: This is done by cleaning the debris,
i. Incision and flap: Cutting the skin or pathological tissues, filling the tissue edge,
mucous membrane and dissecting removing the bone and tooth chips and
through this incision to attain a flap. This finally irrigating the area using saline.
4 A Concise Textbook of Oral and Maxillofacial Surgery
7. Principles of drainage: Wound are drained complete debridement is done. Wound

by following ways closure is done by proper suturing the tissue
i. Fine superficial drains ends.
ii. Large superficial drains 9. Principles of control and prevention of
iii. Deep drains infection of wound: Post-Operative infection
iv. Vacuum drains is reduced by proper pre-operative prepa-
Drains should be inserted into a cavity at ration, an aseptic technique, minimal
its most dependent point and fixed in trauma and adequate drainage. Post-
portion for 2-3 days with regular exami- Operative tissues are protected by proper
nation. dressing and antibacterial therapy.
8. Principles of repair of wounds: Before 10. Principles of support to the patient: Pre and
closure of wound is achieved the surgeon Post-operative care and general support of
should be sure that the procedure was the patient is needed for the overall success
satisfactory, bleeding is arrested and of the surgical procedure.
Diagnosis in Oral and
Maxillofacial Surgery
2
DEFINITION ethnic group, occupation, marital status,

habits.
Case History b. History of present complaint
It is a planned, professional conversation that c. Past medical history
enables patient to communicate symptoms, d. Drug history
feeling, fears and sequence of events leading to e. Family history
problems to the clinician for which the patient f. Past dental history
seeks professional assistance. g. Social history
2. Clinical examination
Diagnosis Inspection
Palpation-extraorally and intraorally
It is an explanation for the patients symptoms Percussion
and identification of other significant disease Auscultation
process. 3. Provisional or presumptive diagnosis
4. Special methods of examination, including:
Treatment Plan Radiographic examination
A plan of treatment usually lists recommended Hematological examination
procedures for control of current disease as well Biochemical examination
as preventive measures designed to limit Histological examination
recurrence or prognosis of the disease process Bacteriological examination
over time. Special tests.
5. Definitive Diagnosis.
Prognosis
IMPORTANCE OF CASE HISTORY
Prognosis is the prediction of the duration,
a. For making correct diagnosis and treatment
course and termination of a disease and its
plan.
response to treatment.
b. Assessment of patients mental and behavioral
status.
METHOD OF DIAGNOSIS
c. Awareness of any systemic diseases.
1. History d. To know the exact nature of medication
a. Personal details: Name, address, patient is taking
telephone number, sex, age, racial or e. For research purposes
f. Expression of interest, warmth and Ewings sarcoma

compassion by clinician, encourages patient Osteosarcoma of the jaw
to communicate their concerns. Burkitts lymphoma
Hodgkins lymphoma
COMPONENTS OF Benign cementoblastoma
PATIENTS HISTORY Basal cell carcinoma
For the recording of patients history we can Squamous cell carcinoma
usehistory questionnaire, computerized data Scarlet fever
gathering technique, open-ended interviewing, Diphtheria
problemoriented recording (POR) or condition Rickets
diagrams (CD). Sickle cell anemia
Infectious mononucleosis
I. Routine Information Pemphigus
1. Name- It is important to know the patient Noma
by name for patients communication and Primary aphthous stomatitis
ease of the patient. Recurrent aphthous stomatitis
2. Age- Certain diseases are particular to that Dental caries
particular age. Nursing bottle caries (children)
Some diseases present at/since birth: Pulp polyp
Facial hemi-hypertrophy Eruption cyst
Macrognathia Dentigerous cyst (2nd decade)
Cleft palate Rheumatoid heart diseases
Double lip Juvenile diabetes
Cleft lip, palate and tongue Some diseases frequently seen in adults and older
Fibromatosis gingivae patients:
Fordyces granules Attrition
Median rhomboid glossitis Abrasion
Developmental lingual salivary gland Gingival recession
depression Periodontitis
Teratoma Acute necrotizing ulcerative gingivitis
Erythroblastosis fetalis Root resorption
Hemophilia Lichen planus
Tetralogy of fallot Leukoplakia
Bronchiolitis Erythroplakia
Some diseases frequently seen in children and Sjgrens syndrome (over 40 years)
young adults: Acinic cell carcinoma
Focal epithelial hyperplasia Necrotising sialometaplasia
Benign migratory glossitis Ameloblastoma (30-50 years)
Papillon- Lefvre syndrome Trigeminal neuralgia
Juvenile periodontitis Glossopharyngeal neuralgia
Osteoid osteoma ot the jaw Fibroma
Torus palatinus Herpes zoster
Kaposis sarcoma Osteomalacia
Diagnosis in Oral and Maxillofacial Surgery 7
Torus mandibularis For example:

Fibrosarcoma of jaw bone i. Filariasis in orissa
Diabetes ii. Leprosy in West Bengal
Peptic ulcer iii. Flourosis in Raichur and Nalgonda district.
It also helps the clinician for further
Child Dose Formulas correspondence
childs age 5. Occupation: It helps in diagnosing certain
a. Young formula = adult dose diseases related to the occupation.
Age + 12 For example:
Child age at i. Varicos vein in bus conductors and traffic
next birthday police due to long time standing.
b. Clarks formula = adult dose ii. Attrition of teeth in cobblers and tailors
24 iii. Erosion is seen in people working in
Age chemical industries.
c. Dillings formula = adult dose
20 II. Chief Complaint of the Patient
3. Sex: Certain diseases effecting sexual organs
will be particular to the sex concerned. Chief complaint is recorded in patients own
Some diseases more common in females: words and should not be translated into technical
Iron deficiency anemia language unless reported in that fashion by the
Caries patient.
Diseases of thyroid Most common chief complaint and their
Pleomorphic adenoma causes are:
Sjgrens syndrome i. Pain
Myasthemia gravis Pulpal disease
Torus palatinus Gingival and periodontal disease
Juvenile periodontitis Salivary gland infection
Cicatrical pemphigoid TMJ disorder
Recurrent apthous stomatitis Maxillary sinus diseases
Malignant melanoma Tonsillar disease
Some diseases more common in males: ii. Burning sensation
Attrition Psychosis
Caries in deciduous teeth Viral infection
Carcinoma in situ Fungal infection
Carcinoma of the buccal mucosa Xerostomic condition
Leukoplakia Fissured tongue
Basal cell carcinoma Anemia
Hodgkins disease Vitamin deficiency
Ameloblastic fibro-odontoma iii. Bleeding
Basal cell adenoma Gingivitis
Pernicious anemia Periodontal disease
4. Address: It is helpful to communicate with Allergy
the patient. Few diseases are distributed to Traumatic injury
particular areas; Deficiency of coagulation factors
iv. Loose teeth Decreased salivary flow

Loss of supporting bone and resorption Intraoral malignancy
of root x. Parasthesia and anesthesia
Periodontal disease Injury to regional nerve- anesthetic needle
Trauma and jaw bone fracture
Malignant tumor Malignancy
Myxoma Medications like those used in sedation,
Hemangioma hypnosis
Papillon-Lefvre syndrome. Pernicious anemia
v. Recent occlusal problems Acute infection of jaw bones.
Periodontal disease xi. Halitosis
Traumatic injury Poor oral hygiene
Cyst and tumor of tooth bearing region Periodontal disease
of jaw Third molar opercula
Fibrous dysplasia Decayed tooth
vi. Delayed tooth eruption ANUG
Malposed or impacted teeth Oral cancer
Cyst Spicy foods
Tumor Tobacco use
Cleidocranial dysplasia Nasal infection
Hypothyroidism Tonsillitis
vii. Xerostomia Gastric problems
Local inflammation Diabetes
Dehydration state
Drugs like tranquilizers and antihistamines III. History of Present Illness
Autoimmune disease like Sjgrens
Patient may or may not volunteer a detail history
syndrome and Mikuliczs disease
of the problem for which they are taking
Post radiation changes
treatment for and additional information usually
Psychosis
needs to be elicited by the examiner. The
viii. Swelling
patients response to these questions constitutes
Inflammation and infection
the history of present illness.
Retention phenomenon
These include the mode of onset, symptoms
Inflammatory hyperplasia
in the exact order to which aggravating and
Benign tumor
relieving factors are used.
Malignant tumor
ix. Bad taste
IV. Past Dental History
Heavy smoking
Poor oral hygiene It is the component of the patients history that
Dental caries is particularly pertinent in the education of the
Periodontal disease dental patient significant items that should be
ANUG recorded are:
Diabetes a. The frequency of past treatment, previous
Medication restorative, periodontic, endodontic or oral
Psychosis surgical treatment.
b. Reasons for loss of teeth towards v. Medication: A medication history is essential

complication of dental treatment. for identifying drug induced disease and
c. Attitude towards previous dental treatment. avoiding untoward drug administration,
d. Experience with orthodontic appliance and when selecting local anesthetic or other
dental prosthesis. medications indicated in dental treatment.
e. Flouride history including supplement and vi. Pregnancy: A negative urine or serum
the use of well water pregnancy test is required in suspected cases
f. Radiation or other treatment for facial or oral before administration of drug. It helps us to
lesion. prescribe a medication or procedure
involving exposure to ionizing radiation or
V. Past Medical History drugs with known or unknown teratogenic
potential.
It includes information about any significant or
serious illness a patient may have or had as a
VI. Family History
child or as an adult and is organized into
following subdivisions: It gives information about disease that commonly
i. Serious or significance illness effect more than 1 member of family such as
Patient is or was routinely medicated migraine, some neurological and mental
Heart, liver, kidney or lung disease disorder, cer tain allergic disorder and
Allergic reactions, infectious disease cardiovascular diseases.
Immunological disorder or steroid therapy Inherited anatomic anomalies such as
Diabetes or hormonal problem congenitally missing lateral incisors, amelogenesis
Radiation or cancer chemotherapy or imperfecta can also be diagnosed by family
immunosuppression. history recording.
Psychiatric treatment
History of spontaneous bleeding VII. Social and Occupational History
associated with extract period (personal history)
Therapeutic radiation to head and neck
It provides important background information
Seizure disorders
to a patients problem as well as suggests possible
Heart murmurs, rheumatic fever or
etiologies related to the social activities, the
congenital heart disease
workplace or travel.
Neuropathy associated with a regional
These include:
oral surgery.
a. Habits including smoking, drinking, which
ii. Hospitalization: A record of hospital
causes oral mucosal and periodontal changes.
admission, complements the information
b. Diet Vegetarian or non-vegetarian
collected on serious illness and may reveal
c. Menstrual history and number of
significant events not previously reported.
pregnancies, miscarriages, whether deliveries
iii. Blood transfusion: It is important in evaluating
are normal or not, in a women.
medical strains and to prevent transmissible
infectious diseases.
VIII. General Examination
iv. Allergies: History of allergies and reactions
such as urticaria, hay fever, asthma, 1. Built: A clinical diagnosis may be achieved
untoward reactions to medication, food and from a look on the built of the patient, it is
diagnostic procedures. significant in endocrine abnormalities.
2. Gait: This indicates the way the patient walks. 6. Cyanosis: It is a bluish discolouration of the
Abnormal gait occurs due to skin and mucous membrane due to increased
a. Bone and joint abnormalities reduced hemoglobin more than 5 gm
b. Muscle and neurologic disorder percent.
c. Structural abnormality Types of cyanosis:
d. Psychiatric disease. 1. Central caused due to defect in lung and
Types of Gait: heart
a. Wadding 2. Peripheral caused due to block in circulation
b. Equinus in tissue
c. Scissor 3. Mixed seen in congestive cardiac failure
d. Hemiplegic 4. Differential
e. Steppage Difference in central and peripheral cyanosis:
f. Shuffling
g. Wobbly Central cyanosis Peripheral cyanosis
h. Staggering a. Extremities are warm a. Extremities are cold
i. Ataxic gaits. b. No change on b. Warming the extremities
3. Nourishment: Affects the built of a person. warming extremities cyanosis disappear
4. Pallor: It is the paleness of skin and mucous c. By giving oxygen central c. No change on
cyanosis disappear giving oxygen
membrane either as a result of diminished d. Seen in tip of nose d. Not seen in this region
circulating red blood cells or diminished and tongue
blood supply. Pallor is detected in the Examples: Examples:
palpebral part of the conjunctiva, skin and Fallots tetralogy Mitral stenosis
mucous membrane. C.C.F C.C.F
A.V fistula Shock
Causes Cirrhosis Raynauds disease
Methemoglobinemia Cold exposure
1. Anemia Sulphemoglobinemia
2. Shock Brochitis (chronic)
3. Peripheral vascular diseases.
Sites where anemia is detected: 7. Clubbing: It is the bulbous swelling of the
Lower palpebral conjunctiva tip of the finger and toe.
Tongue Causes:
Soft palate i. Respiratory cause
Palm and nails Bronchitis
5. Icterus: Icterus is a condition which is seen Bronchogenic carcinoma
in jaundice and is characterized by yellow Lung abscess
discolouration of tissues and body fluids due Interstitial lung disease
to an increase in bile pigments. It may arise Empyema
due to: ii. GIT/Abdominal cause
Increased bile pigment load to the liver Ulcerative colitis
Affection of bilirubin diffusion into the Malabsorption syndrome
liver cells Biliary cirrhosis
Defective conjugation Crohns disease
Defective excretion iii. Cardiovascular cause
Icterus is detected in the bulbar part of the Infective endocarditis
conjunctiva, nail, skin and oral cavity. Cyanotic congenital heart disease
iv. Endocranial cause Types of Fever

Myxoedema
Continuous- fluctuates less than 1C; does
Thyrotoxicosis
not touch base line.
Acromegaly
Grading of Clubbing
Grade I Softening of nail bed with
obliteration of angle of nail bed
Grade II Increase in anteroposterior
curvature
Grade III Increase anteroposterior and Intermittant- goes up and touches line.
transverse curvature
Grade IV Hypertropic osteoarthropathy
8. Edema: Edema is the collection of fluid in
the interstitial spaces or serous cavities. It
becomes evident only when 5-6 litres of fluid
have accumulated in the water depots.
Pitting on pressure occurs when the
Remittant- fluctuates more than 1C and does
circumference of the limb is increased by
not touch base line
10 percent.
Types:
i. Nonpitting edema in myxedema and
filariasis
ii. Pitting edema in cardiac, liver, hypo-
protenemia and renal disturbances.
9. Ecchymosis and petechiae: These are
hemorrhagic abnormalities of the skin. Pel Ebstein type- there is a regular alteration
Ecchymosis is an hemorrhages more than of recurrent bouts of fever and afebrile
5 cm in diameter, whereas petechiae are tiny periods.
hemorrhage less than 1mm in diameter. Step ladder type- seen in typhoid.
10. Pulse: 12. Respiratory Rate: The normal respiratory
The normal pulse rate is 70-100/min rate is 18-20/min. when it is less than
When it is increased more than 100/min 14/min then it is termed as bradypnea
then it is termed as tachycardia whereas when it is more than 20/min then
Which it is decreased and less than 60/ it is termed as tachypnea
min than it is termed as bradycardia 13. Blood pressure: Blood pressure is the lateral
11. Temperature: The normal temperature is pressure exerted by the contained column
98.4F less than 94F is termed as of blood on the wall of arteries.
hypothermic whereas as more than 106F The normal blood pressure is 120 (systolic)/
is termed as hyperthermic or heat stroke. 80 (diastolic) (mm of Hg).
JNC classification of blood pressure: Palpating lymph nodes and probable

i. Normal (less than 120/80 mm of Hg) associated conditions:
ii. Prehypertensive state (systolic 120-139/ a. Tender, mobile, enlarged Acute
diastolic 80-89 mm of Hg) infection
iii. Stage I hypertensive (systolic 140-159/ b. Non-tender, mobile, enlarged chronic
diastolic 90-99 mm of Hg) infection.
iv. Stage II hypertensive (systolic more than c. Matted, non tender tuberculosis
180/diastolic more than 100 mm of Hg). d. Fixed, enlarged squamous cell
IX. LOCAL EXAMINATION carcinoma
e. Rubbery, enlarged lymphomas.
A. Extraoral Examination 2. Temporomandibular joint: For temporo-
1. Lymph nodes: Lymph nodes are aggregation mandibular joint abnormalities we need to
of lymphatic tissues present all over the body observe for deviation of mandible during
which helps in drainage. opening and closing as well as during vertical
The lymph nodes that are examined are the and lateral movements, tenderness on
cervical group of lymph nodes (Fig. 2.1), which palpation and presence of any clicking/
includes: popping sound.
Submandibular
Submental B. Intraoral Examination
Jugulodigastric
Preauricular 1. Soft Tissue Examination
Postauricular
Supraclavicular i. Lips: Note the colour of the lip, texture,
and any surface abnormalities, angular
or vertical fissures, lip pits, cold sores,
ulcers, scabs, nodules, sclerotic plaque and
scars.
ii. Labial mucosa: Orifice of minor salivary
glands and granules.
iii. Buccal mucosa: Note any change in
pigmentation and movability of mucosa,
pronounced linea alba, leukoedema,
intraoral swellings, ulcers, nodules, scars,
other red and white patches and fordyces
granules.
iv. Maxillary and mandibular mucobuccal fold:
Observe color, texture, any swelling, fistula,
Fig. 2.1: Location of the lymph nodes palpate for swelling and tenderness over the
of head and neck region roots of teeth and tenderness of buccainator
Types of lymph node inflammation: insertion.
i. Non-significant Where only 1 lymph node v. Palate (hard and sof t): Inspect for
is involved, it is non tender and discrete. discoloration, swelling, fistula, papillary
ii. Significant Where more than 1 cm size hyperplasia, tori, ulcers, hyperkeratinisation,
increase is present and lymph node is tender asymmetry of structure, function and orifice
and fixed. of minor salivary glands.
vi. Floor of mouth: Observe for the opening INVESTIGATIONS

of Whartons duct and other abnormalities.
To confirm the diagnosis, a series of investi-
vii. Tongue: Dorsum of the tongue should be
gations are carried out. They are:
observed for any swelling, ulcer, and
1. Hematological investigations
variations in colour, size and texture.
2. Urine analysis
viii. Gingiva: Observe for the colour, contour,
3. Biochemical investigations
consistency, shape, size, surface texture,
4. Radiological investigations
position, bleeding on probing and exudation
5. Histopathological investigations
on pressure.
6. Microbiological investigations
ix. Oropharynx: Observe for the tonsils and
pharynx and note for colour, size and
1. Hematological Investigations
surface abnormalities.
x. Saliva: Check for the quantity and quality Normal value
of saliva. i. Hemoglobin (Hb) = 12-14 gm percent
(females)
2. Hard Tissue Examination 14-18 gm percent
(males)
i. Teeth present ii. Total RBC = 4.5-5 million
ii. Teeth missing (females)
iii. Mobility 5-6 million (males)
grade I iii. Total WBC = 4,000-11,000/cu
grade II mm.
grade III iv. Total platelet = 1.5 lakhs/cu mm.
iv. Dental caries v. (DLC) Differential
v. Restored teeth leukocyte count = Neutrophil
vi. Retained teeth 50-70 percent
vii. Discoloured teeth Lymphocyte
viii. Calculus/stain 25-40 percent
ix. Occlusion Monocytes
x. Any other abnormalities. 3-8 percent
Eosinophil
PROVISIONAL DIAGNOSIS 1-8 percent
It is the art of using scientific knowledge to identify Basophil-0-1 percent
oral disease, process and to distinguish one vi. Bleeding time(BT) = 3-5 minutes
disease from the other. vii. Clotting time(CT) = 4-10 minutes
viii. Random Blood
glucose (RBG) = 80-150 mg percent
DIFFERENTIAL DIAGNOSIS
ix. Fasting Blood
It is the process of identifying condition by glucose (FBG) = 60-100 mg percent
differentiating it from all pathological process that x. Post prandial blood
produce similar lesion. glucose (PPBS) = 100-180 mg percent
xi. Blood urea = 10-20 mg percent v. Serum billirubin

= 0.2-1 mg percent
xii. Prothrombin time vi. Serum protein = 6-8 gm percent
(PT) = 11-15 sec vii. SGOT = 8-40 unit/ml
xiii. Erythrocyte = 0-20 minutes /hr viii. SGPT = 5-35 unit/ml
sedimentation (females) ix. Serum
calcium = 9-11 mg percent
rate (ESR) (by Wintrobe x. Serum
cholesterol = 150-250 mg
method) percent
0-10 minutes/hr xi. Serum triglyceride = 10-190 mg percent
(males) xii. Serum HDL = 30-75 mg percent
xiv. Partial thrombo- xiii. Serum LDL = 80-210 mg percent
plastin time (PTT) = 25-45 seconds xiv. Serum VL DL = 5-40 mg percent
xv. Serum sodium = 135-145 m Eq/L
2. Urine Analysis xvi. Serum potassium = 3.2-5.5 m Eq/L
i. Colour = light yellow, early xvii. Serum chloride = 95-105 m Eq/L
morning urine is dark
ii. Volume = 1000-1500 ml/day 4. Radiological Investigations
iii. Odour = light aromatic odour, i. Intraoral radiographic techniques
on standing, odour a. Intraoral periapical radiographs (IOPAR)
becomes stronger due b. Occlusal radiographs
to bacterial c. Bitewing radiographs
decomposition ii. Extraoral radiographic techniques
iv. Reaction = Slightly acidic a. Posterio-anterior projection
(pH = 4.5 6) b. Lateral skull projection
v. Specific gravity = 1.010 1.025 c. Waters/occipitomental projection
vi. Urine glucose = absent d. Reverse towne projection
vii. Urine blood = absent e. Submentovertex projection
viii. Urine ketone, f. Mandibular projection
bile, bilirubin, iii. Specialised radiographic techniques
bacteria = absent a. Orthopantamography (OPG)
ix. Urine protein = 35 mg per day b. Tomography
x. Urine epithelial c. Ultrasonography
cells, hyaline d. Zero radiography
cells = occasional e. Stereoscopy
f. Scanography
3. Biochemical Investigations
g. Digital imaging/radiovisiography
i. Serum Creatinine = 0.7-1.4 mg percent h. Digital substraction radiography
ii. Serum Uric acid = 2.5-8 mg percent i. Nuclear medicine
iii. Serum alkaline j. Magnetic resonance imaging (MRI)
phosphatase = 3-13 KA unit k. Thermography
iv. Serum acid l. Cine radiography
phosphatase = 0.6-3 KA unit m. Sialography
Structure to be Radiographic technique 3. Screening of normal tissues from abnormal

viewed or investigated or projection used tissues
1. Maxillary sinus Waters view
4. Diagnosis of malignant and non-malignant
Standard occlusal posterior lesion.
maxillary cross sectional
Uses:
projection
2. All other sinus Waters or paranasal sinus view
1. Diagnosis of pathology
3. Mandibular fracture 2. Grading of tumor
i. condyle Reverse townes projection 3. Determining neoplastic and non-neoplastic
ii. angle Mandibular lateral oblique features
projection (body and ramus) 4. Evaluation of recurrence
iii. body Mandibular lateral oblique
5. Determining the prognosis
projection (body)
iv. canine region Mandibular lateral oblique Complication:
projection (body) 1. Hemorrhage
v. ramus Mandibular lateral oblique
projection (ramus)
2. Infection
vi. coronoid Mandibular lateral oblique 3. Poor wound healing
projection (ramus) 4. Spread to adjacent organs
Waters view
4. Zygomatic fracture Waters view Types:
Submentovertex projection 1. Commonly used
5. Tempromandibular joint Transcranial view Incisional
Transorbital view Excisional
Transpharyngeal view Punch
Reverse townes view
FNAC
6. Parotid gland Intra oral view of cheek
Mandibular lateral oblique Aspiration
projection (ramus) Curettage
7. Submandibular gland Mandibular lateral oblique Scrape
projection (body) 2. Less commonly used
Anterior mandibular Brush
occlusal projection
Cone
Bite
5. Histological Investigation Endoscopic
This is the examination of the cells and tissues Irrigation
collected from the diseased area for the specific Pressure
pathology. Shave
The specimen is collected by biopsy Sponge
procedure and send for laboratory examinations Excisional biopsy: It is a therapeutic as well as
for the report. diagnostic procedure (Fig. 2.2).
Biopsy: It is the study of tissue removed from Indication:
a living organism to confirm the diagnosis Lesions smaller than 1 cm in diameter
through histopathological study. Freely movable lesion
Indications:- Procedure:
1. Diagnosis of any carcinoma Local anesthesia given to area
2. To determine the histological nature of any Excise complete lesion with 2 mm normal
soft tissue or intra mucous lesion tissue boundary
Fig. 2.2: Excisional and incisional biopsy Fig. 2.3: FNAC technique
Fix tissue in 10 percent formalin solution and Fine needle aspiration cytology (FNAC): This is
send to laboratory in transport media a procedure where a 18-gauge fine needle is
Close surgical site with suturing and proper inserted into the lesion and the tissue content
pack. is aspirated, which is thereby send to the
laboratory for examination. It is a very useful
Incisional biopsy:
procedure for diagnosing cystic lesions and
Indication:
differentiating benign lesion from malignant
Large deep and extremely deep lesions (Fig. 2.2)
lesion (Fig. 2.3).
Procedure:
Local anesthesia given to area Transport media: After obtaining the tissue
V shaped incision is made and tissue is specimen it should be kept in a fixative solution
removed along with normal tissue boundary. for fixation. This prevents the autolysis of protein
content of the tissues thus prevents the
Fix tissue in 10 percent formalin solution and
breakdown of protein to amino acids. 10 percent
send to laboratory in transport media.
formalin (10 parts of 40% formalin + 90 parts
Close surgical site with suturing and proper
of water) is mostly used fixative which changes
pack.
the tissue protein framework, thus facilitating
Punch biopsy: sectioning and strengthening the protein linkage
Indication: Rarely needed in oral cavity as most against breakdown during the staining process.
of the lesions are easily accessible. It is done in Before fixing the tissue they should be
areas where lesion is small and inaccessible. properly washed in normal saline to remove
excess blood as haematin of hemoglobin reacts
Procedure:
with formalin, thus reducing its concentration
Shallow hollow tube is rotated until
and action.
underlying bone or muscle is reached.
In case where formalin is not available, local
Tissue is removed and site is secured
anesthetic solution can also be used. The
similar to that of incisional and excisional
analgesic content maintains the tonicity and
biopsy. sodium bisulfite present acts as a preservative.
Brush biopsy:
Exfoliative cytology: It is the study of exfoliated
Most advanced technique for oral mucosa
or abraded cells and tissues.
biopsy
Disposable brush is used to collect Features:
transepithelial sample of cells. It is not a substitute but an adjunct to biopsy
It is quick, simple, painless and bloodless 6. Microbiological Investigations

procedure. These are the test for the micro-organisms-
It helps in checking false negative biopsy bacterias, fungi, virus, protozoa etc.
It is helpful for follow up examination of Blood, sputum, serum and other specimen
carcinoma are collected and examined for microbiology.
It is mostly helpful for areas not reached by For septicemia- aerobic and anaerobic cultures
biopsy like in GIT should be considered.
Procedure: Various special methods are available besides
Clean oral surface of debris and mucosa. the routine eosin and haematoxylin smears.
Vigorously scrape the entire lesion surface, These are:
using a metal spatula or moistened tongue Z N staining (Ziehl-Neelsen)
blade or cytobrush. ELISA
Collected specimen is than quickly placed PCR
over slide. Culture methods
Fixing is done by fixating solution like PAC staining
absolute alcohol or equal quantities of alcohol Immunofluoroscence test
and ether but never heat fixed. VDRL
Second slide preparation using other scraping Serological tests
is also required. Treatment Plan
Limitations: A treatment plan is a carefully sequenced series
Presence or extent of invasion is not assessed. of services designed to eliminate or control
Most oral benign lesions do not answer to etiologic factors, repair existing damage and
this procedure like fibroma, leukoplakia. create a functional maintainable environment.
Negative cytology report cannot rule out Treatment planning depends on:
cancer but is recommended for biopsy. 1. Patient evaluation
2. Dentists expertise
Advantages: 3. Understanding indications and contraindi-
Other diseases having specific cells are also cations
diagnosed like Herpes simple, herpes zoster, 4. Predictions of patients response after treat-
pernicious anaemia etc. ment.
The process is used for forensic odontology.
FURTHER READING
Report study:
Class I Normal 1. Greenberg and Glick Burkets oral medicine,
diagnosis and treatment, 10th ed.
Class II Atypical (presence of minor atypia 2. Mamm CV, Russell-R.C.G. Bailey and Loves
but no malignancy) short practice of surgery, 21st ed 1992.
Class III Intermediate (between cancer and 3. Peterson, Ellis, Hupp, Tucker Contemporary
no cancer- wide atypia suggests cancer but is oral and maxillofacial surgery, 4th ed 2006.
not clear cut, so told to be pre-malignant). Biopsy 4. RA Cawson Essentials of Dental Surgery and
is recommended. Pathology, 5th ed.
Class IV - Suggestive of cancer (few malignant 5. Shafer-Hine-Levy Shafers textbook of Oral
Pathology, 5th ed 2006.
and few border line cells seen). Biopsy is 6. SP Mehta, SP Joshi PJ Mehtas practical
mandatory. medicine, 18th ed 2007.
Class V Positive for cancer (malignant cells 7. White and pharoah Oral Radiology, Principles
seen). Biopsy is mandatory. and Interpretations 5th ed. 2006.
Management of Medically
Compromised Patients 3
and Medical Emergencies
INTRODUCTION 3. Hyperthyroidism
4. Diabetes
Medical emergency is an unforeseen or an
5. Anxiety
unexpected circumstances requiring immediate
IV. Other conditions:
attention. Fortunately medical emergencies are
1. Renal insufficiency
rare in dental practice but any clinician should
2. Hepatic insufficiency
have a thorough knowledge of the medical
3. Anticoagulant therapy
emergencies to overcome them if any arise.
4. Seizure disorder
Preparation of the clinician to handle medical
5. Hypersensitivity
emergencies are:
1. Personal containing education in emergency 6. Hyperventilation
recognition and management. 7. Syncope
2. Auxiliary staff education in emergency 8. Shock
recognition and management. 9. Tachyphalaxis
3. Establishment and periodic testing of a 10. Local anesthesia toxicity
system to readily access medical assistance 11. Foreign body aspiration
when an emergency occurs. 12. Hemorrhage
4. Equipping office with supplies necessary for 13. Pregnancy.
emergency care.
Management of some common medical I. CARDIAC CONDITIONS
emergencies occurring in a dental practice:
Features Confirming Cardiac Disorder
I. Cardiac conditions:
1. Angina pectoris Chest discomfort on exertion, when eating
2. Congestive cardiac failure or at rest.
3. Hypertension Palpitation
4. Myocardial infarction Fainting
II. Respiratory conditions: Ankle edema
1. Asthma Dyspnea on exertion and on assuming supine
2. COPD position
III. Hormonal conditions: Postural hypotension
1. Hypoglycemia Fatigue
2. Adrenal suppression and insufficiency Leg muscle cramping
Management of Medically Compromised Patients and Medical Emergencies 19
Management of Patient 3. Use an anxiety reduction protocol.

with Angina Pectoris 4. Avoid rapid posture changes in patients
taking drugs that cause vasodilatation.
1. Consult patients physician 5. Avoid administration of sodium- containing
2. Use anxiety reduction protocol. intravenous (I.V) solutions.
3. Have nitroglycerin tablets or spray readily
available (use premedication if needed). Severe hypertension:- (BP more than 200/110
4. Administer supplemental oxygen. mm of Hg)
5. Ensure profound local anesthesia before 1. Defer elective dental treatment until
starting surgery hypertension is better controlled.
6. Consider use of nitrous oxide sedation 2. Consider referral to oral and maxillofacial
7. Monitor vital signs closely surgeon for emergency problems.
8. Possible limitation of amount of adrenaline
to 0.04 mg maximum (4 ml of LA with 1: Management of Patient with
1,00,000 adrenaline) Myocardial Infarction
9. Maintain verbal contact with patient
1. Same as managing a patient with Angina.
throughout procedure to monitor status.
2. Defer surgery if possible for 6 months post
MI attack.
Management of Patient with 3. Administer oxygen.
Congestive Cardiac Failure 4. Check if patient is taking anticogulants.
1. Defer treatment until heart function has been
medically improved and physician believes II. RESPIRATORY CONDITIONS
treatment is possible. Features confirming respiratory disorders:-
2. Use anxiety reduction protocol. Perspiration
3. Possible administration supplemental oxygen Tachycardia
4. Avoid supine position Wheezing (audible with or without
5. Consider referral to oral and maxillofacial stethoscope)
surgeon Coughing
6. An upright patient position is preferred Excessive sputum production
during treatment. Hemoptysis (coughing blood)
Dyspnea with exertion.
Management of Patient
with Hypertension Management of Patient with Asthma
Mild to moderate hypertension (BP more than 1. Defer dental treatment until asthma is well
140/90 mm of Hg) controlled and patient has no signs of a
1. Recommend that the patient seeks the respiratory tract infection.
primary care physician guidance for medical 2. Listen to chest with stethoscope to detect
therapy of hypertension. wheezing before major oral surgical
2. Monitor the patients blood pressure at each procedures or sedation.
visit and whenever administration of 3. Use anxiety reduction protocol, including
adrenaline- containing local anesthesia nitrous oxide, but avoid use of respiratory
surpasses 0.04 mg during a single visit. depressants.
4. Consult physician about possible use of Management of a Patient with

preoperative cromolyn sodium. Chronic Obstructive Pulmonary
5. If patient is or has been chronically on Disease (COPD)
corticosteroids, prophylax for adrenal 1. Defer treatment until lung function has
insufficiency. improved and treatment is possible.
6. Keep a bronchodilator containing inhaler 2. Listen to chest bilaterally with stethoscope to
easily accessible. determine adequacy of breath sounds.
7. Avoid use of nonsteroidal anti inflammatory 3. Use anxiety reduction protocol, but avoid use
drugs (NASIDs) in susceptible patients.
of respiratory depressants.
8. Afternoon or midday appointments are
4. If patient is on chronic oxygen supplemen-
preferred.
tation, continue at prescribed flow rate. If
patient is not on supplement oxygen therapy,
Management of Patient with Acute consult physician before administering
Asthmatic Episode Occurring during oxygen.
Dental Sugery 5. If patient chronically receives corticosteroid
1. Terminate all dental procedures therapy, manage patient for adrenal
2. Position patient in fully sitting posture insufficiency.
3. Administer bronchodilator by spray 6. Avoid placing patient in supine position until
4. Administer oxygen confident that patient can tolerate it.
5. 7. Keep a bronchodilator- containing inhaler
accessible.
8. Closely monitor respiratory and heart rates.
9. Schedule afternoon appointments to allow
for clearing of secretions.
III. HORMONAL CONDITIONS
Features Confirming Acute
Hypoglycemia
Mild Hypoglycemia
Hunger
Nausea
Mood changes
Weakness
Moderate Hypoglycemia
Tachycardia
Perspiration
Pallor
Anxiety
Behavior change:
Belligerence
Confusion
Uncooperativeness.
Severe Hypoglycemia Management of Patient Suffering

Hypotension from Acute Adrenal Insufficiency
Unconsciousness
Seizures. 1. Terminate all dental treatment.
2. Position patient in supine position, with legs
Management of Patient Suffering raised above level of head.
from Acute Hypoglycemia 3. Have someone summon medical assistance.
4. Administer corticosteroid (100 mg of
1. Terminate all dental treatment hydrocortisone or its equivalent) I.M or I.V
For Mild Hypoglycemia: 5. Administer oxygen
2. Administer glucose source such as sugar or 6. Monitor vital signs.
fruit by mouth. 7. Start I.V line and drip of crystalloid solution.
3. Monitor vital signs. 8. Start basic life support, if necessary.
4. Before further dental care, consult physician, 9. Transport to emergency care facility.
if unsure whether or why hypoglycemia has
occurred. Management of Patient Suffering
from Hyperthyroidism
For Moderate Hypoglycemia:
2. Orally administer glucose source, such as 1. Defer surgery until thyroid dysfunction is well
sugar or fruit juice controlled.
3. Monitor vital signs. 2. Monitor pulse and blood pressure before,
4. If symptoms do not rapidly improve, during and after surgery.
administer 50 ml 50 percent glucose or 1 3. Limit amount of epinephrine used.
mg glucagon intravenously (I.V) or
intramuscularly (I.M). Management of Patient Suffering
5. Consult physician before further dental care. from Diabetes
For Severe Hypoglycemia:
Insulin Dependent Diabetes
2. Administer 50 ml, 50 percent glucose IV or
IM or 1mg glucagon. 1. Defer surgery until diabetes is well
3. Have someone summon medical assistance controlled; consult physician.
4. Monitor vital signs 2. Schedule an early morning appointment;
5. Administer oxygen. avoid lengthy appointments.
6. Transport to emergency care facility. 3. Use anxiety reduction protocol, but avoid
deep sedation techniques in outpatients.
Features Confirming Acute 4. Monitor pulse, respiration and blood
Adrenal Insufficiency pressure before, during and after surgery.
Weakness 5. Maintain, verbal contact with patient during
Feeding of extreme fatigue surgery
Confusion 6. If patient must not eat or drink before oral
Hypotension surgery and will have difficulty eating after
Nausea surgery, instruct patient to not take the usual
Abdominal pain dose of regular or neutral protamine
Myalgias hagedorn insulin; start an I.V with an D5
Partial or total loss of consciousness. W drip at 150 ml/hour.
7. If allowed, have the patient eat a normal During Appointment

breakfast before surgery and take the usual Non-pharmacological means of anxiety control
dose of regular insulin but only half the Frequent verbal reassurances
dose of NPH insulin. Distracting conversation
8. Advise patients not to resume normal insulin No surprises (clinician warns patient before
doses until they are able to return to usual doing anything that could cause anxiety).
level of caloric intake and activity level. No unnecessary noise.
9. Consult physician if any questions Surgical instruments out of patients sight.
concerning modifications of the insulin Relaxing background music.
regimen arise.
Pharmacologic means of anxiety control
10. Watch for signs of hypoglycemia.
Local anesthetics of sufficient intensity and
11. Treat infections aggressively.
duration.
Nitrous oxide.
Non-insulin Dependant Diabetes
Intravenous anxiolytics.
1. Defer surgery until diabetes is well controlled.
After surgery
2. Schedule an early morning appointments;
Succinct instruments for post operative care.
avoid lengthy appointments.
Patient information on expected post surgical
3. Use an anxiety reduction protocol.
sequel.
4. Monitor pulse, respiration and blood
Further reassurance
pressure before, during and after surgery.
Effective analgesics
5. Maintain verbal contact with the patient
Patient information on who can be contacted
during surgery.
if any problems arise.
6. If patient must not eat or drink before oral
Telephone call to patient at home during
surgery and will have difficulty eating after
evening after surgery to check if any
surgery, instruct patient to skip any oral
problems exist.
hypoglycemic medications that day.
7. If patient can eat before and after surgery,
instruct patient to eat a normal breakfast and IV. OTHER CONDITIONS
to take the usual dose of hypoglycemic Management of Patients
agent. with Renal Insufficiency
8. Watch for signs of hypoglycemia.
9. Treat infections aggressively. 1. Avoid the use of drugs that depend on renal
metabolism or excretion. Modify the dose if
Management of Patients with Anxiety such drugs are necessary.
(Anxiety Protocol) 2. Avoid the use of nephrotoxic drugs, such as
non-steroidal anti inflammatory drugs.
Before Appointment 3. Defer dental care until the day after dialysis
Hypnotic agent to promote sleep on night has been given.
before surgery (optional) 4. Consult physician concerning use of
Sedative agent to decrease anxiety on prophylactic antibiotics.
morning of surgery (optional). 5. Monitor blood pressure and heart rate.
Morning appointment and schedule so that 6. Look for signs of secondary hyper-
reception room time is minimized. parathyroidism.
7. Consider hepatitis B screening before dental 6. Take some extra measures during and after
treatment. Take hepatitis precautions if surgery, to help promote clot formation and
unable to screen for hepatitis. retention.
7. Restart warfarin on the day of surgery.
Management of Patient
with Hepatic Insufficiency Patients receiving Heparin:
1. Consult the patients physician to determine
1. Attempt to learn the cause of the liver
the safety of stopping heparin for the
problem; if the cause is hepatitis B, take usual
perioperative period.
precautions.
2. Defer surgery until at least 6 hours after the
2. Avoid drugs requiring hepatic metabolism or
heparin is stopped or reverse heparin with
excretion; if there use is necessary, modify
protamine.
dose.
3. Restart heparin once a good clot has formed.
3. Screen patients with severe liver disease for
bleeding disorders with platelet count, Management of Patient with
prothrombin time, partial thromboplastin a Seizure Disorder
time and bleeding time
1. Defer surgery until the seizures are well
4. Attempt to avoid situations in which the
controlled
patient might swallow large amount of blood.
2. Consider having serum levels of anti seizure
Management of Patient with medications measured if patient compliance
Anticoagulant Therapy is questionable.
Patient receiving aspirin or other platelet 3. Use anxiety reduction protocol.
inhibiting drug: 4. Avoid hypoglycemia and fatigue.
1. Consult physician to determine the safety of Manifestation and Management of
stopping the anticoagulant drug for several Hypersensitivity (Allergic) Reactions
days.
2. Defer surgery until the platelet inhibiting drugs Manifestations Management
have been stopped for 5 days. Skin signs
3. Take extra measures during and after surgery a. Delayed onset i. Stop administration of all
skin signs: erythema, drugs presently in use
to help promote clot formation and
Pruritis, angioedema ii. administer IV or IM
retention. Benadryl 50 mg
4. Restart drug therapy on the day after surgery iii. refer to physician
if no bleeding is present. iv. prescribe oral
antihistamine, such as
Patients receiving Warfarin (coumarins): Benadryl 50 mg q6h
1. Consult the patients physician to determine b. Immediate onset i. stop administration of all
the safety of allowing the prothrombin time skin signs: erythema, drugs presently in use
Pruritis, urtricaria ii. administer epinephrine
to fall to 1.5 INR for a few days. 0.3 ml of 1: 1000
2. Obtain the baseline prothrombin time. subcutaneously.
3. a. if the PT is 1 to 1.5 INR, proceed with iii. administer antihistaminic
surgery and skip to step 6. IM or IV.
iv. monitor vital signs
b. the PT is more than 1.5 INR, go to step 4. v. consult patients physician
4. Stop warfarin approximately 2 days before vi. observe in office for
surgery. one hour
5. Check the PT daily and proceed with surgery vii. prescribe Benadryl
50 mg q6h.
on the day when the PT fails to 1.5 INR
Respiratory tract signs with or without cardiovascular or skin Features Confirming Hyperventilation
signs
a. Wheezing, mild dyspnea i. stop administration of all Neurologic:
drugs presently in use. Dizziness
ii. place patient in sitting
Tingling or numbness of fingers, toes or lips
position
iii. administer adrenaline Syncope
iv. provide I.V access
v. consult patients physician or Respiratory:
emergency department Increased rate and depth of breath
physician Feeding of shortness of breath
vi. observe in office for at least Chest pain
1 hour
vii. prescribe antihistamine
Xerostomia
b. Stridorous breathing i. stop administration of all
(i.e crowding sound) drugs presently in use. Cardiac:
moderate to ii. sit the patient upright and Palpitations
severe dyspnea. have someone summon Tachycardia
medical assistance.
iii. administer adrenaline Musculoskeletal:
iv. give oxygen (6 L/Min) by Myalgia
face mask or nasally
v. monitor vital signs frequently Muscle spasm
vi. administer antihistamine Tremor
vii. provide IV access; if signs Tetany
worsen treat as for
anaphylaxis Psychologic:
viii. consult patients physician Extreme anxiety.
or emergency room
physician; prepare for
transport to emergency Management of Patient with
room if signs do not Hyperventilation
improve rapidly.
c. Anaphylaxis (with or i. stop administration of all 1. Terminate all dental treatment and remove
without skin signs): drugs presently in use.
malaise, wheezing, ii. position patient supine on foreign bodies from mouth.
moderate to severe back board or on floor and 2. Position patient in chair in almost fully upright
dyspnea, stridor, have someone summon position
cyanosis, total assistance. 3. Attempt to verbally calm patient
airway obstruction, iii. administer epinephrine
4. Have patient breathe CO2 enriched air,
nausea, and vomiting, iv. initiate basic life support
abdominal cramps, and monitor vital signs such as in and out of a small bag.
urinary incontinence, v. consider cricothyrotomy if 5. If symptoms persist or worsen, administer
tachycardia, trained in use and if diazepam, 10 mg I.M or titrate slowly I.V until
hypotension, laryngospasm is not quickly anxiety is relieved, or administer midazolam
cardiac dysrythmias, relieved with epinephrine.
cardiac arrest. vi. provide I.V access.
5 mg IM or titrate slowly IV until anxiety is
vii. give oxygen 6 L/Min. relieved
viii. administer antihistamine 6. Monitor vital signs
IV or IM 7. Perform all further dental surgery using
ix. prepare for transport
anxiety reducing measures.
Syncope 2. Loosen tight clothing.

3. Maintain airway (Remove any obstruction in
It is transient loss of consciousness due to cerebral
path)
anoxia (reduced cerebral perfusion) thus inable
4. Inhalation of aromatic spirit of ammonia
to maintain posture.
(helps securing reflex stimuli)
Types 5. Oxygen administration
6. Maintain vital signs
1. Cardiac syncope 7. If unconsciousness for longer time than treat
2. Vasovagal syncope cause.
3. Postural syncope
4. Drug induced syncope
5. Cerebrovascular syncope Prodrome
1. Terminate all dental treatment
Pathophysiology and Manifestation of 2. Position patient in supine position with legs
Vasovagal Syncope raised above level of head.
3. Attempt to calm patient
4. Place cool towel on patients forehead
5. Monitor vital signs
Syncopal Episode
1. Terminate all dental treatment
2. Position patient in supine position with legs
raised
3.
Management Shock
1. Maintain supine position with legs lifted above It is hemodynamic disturbance where there is
head, therefore increased blood to brain. systemic hypoperfusion of tissues and organs.
Pathogenesis and Classification iii. Irreversible stage

Decrease in blood pressure
Type Cause Mechanism Decrease in cardiac output
1. Hypovolaemic -Haemorrhage, -Decrease in blood Tachypnea
shock trauma volume Decrease blood to vital organ and
- fluid loss, specific features
burns
2. Cardiogenic - Myocardial -Decrease in Can lead to death.
shock infarction cardiac output Pale lips, nails, finger, ear lobe and mucous
3. Septic shock -Endotoxins -Peripheral membrane
vasodilatation Sunken eye
-Pooling of blood
Weak pulse
in periphery
4. Neurogenic -During -Peripheral Shallow respiration
shock anesthesia vasodilatation and Abnormal temperature.
-Spinal cord pooling of blood
injury in periphery Management
5. Anaphylactic shock - Anaphylaxis -Peripheral
vasodilatation and It can be easily prevented than treated:
pooling of blood in 1. Supine position with head below the feet
periphery should be positioned.
2. Oxygen inhalation
3. Maintain airway, and it may need
tracheostomy.
4. Monitor vital signs
5. Maintain body heat by covering with blanket
and hot packs.
6. Restore lost body fluid.
7. Treat cause and symptomatic relief should
be provided.
8. Injection hydrocortisone and atropine
sulphate, antibiotics, adrenaline.
Tachyphylaxis
It is the falling off in the effect produced by a
drug during continuous use or constantly
repeated administration.
Features It is mainly seen in drugs of nervous
Three stages in shock are: systems.
i. Early/compensatory/non progressive stage: Eg:- Pain returns back before re-injection.
Tachycardia This occurs due to:
Peripheral vasoconstriction Oedema
ii. Progressive stage: Localized bleeding
Decrease in blood pressure Clot formation
Decrease in cardiac output Hypernatremia
Tachypnea Decrease PH of tissues
Local Anesthesia Toxicity Contd....
Manifestations and Management of LA toxicity Manifestation Management
Manifestation Management objects; suction oral cavity

i. Mild toxicity: Stop administration of if vomiting occurs
talkativeness, local anesthetics. have someone summon
anxiety, slurred Monitor all vital signs. medical assistance
speech, confusion. Observe in office for 1 hour. Monitor all vital signs
ii. Moderate toxicity: Stop administration of administer oxygen
stuttering speech, local anesthetics. start I.V
nystagmus, tremors, Place in supine position administer diazepam
headache, dizziness, Monitor all vital signs. 5-10 mg slowly or
blurred vision, Administer oxygen midazolam 2-6 mg
drowsiness Observe in office for 1 hour. institute basic life support
iii. Severe toxicity: Place in supine position if necessary.
Seizure, cardiac if seizure occurs, protect Transport to emergency
dysrhythmia or arrest patient from nearby care facility.
Contd....
Management of Respiratory Tract Foreign Body

Aspiration in Patient Undergoing Dental Surgery
1. Terminate all dental treatment.
2. Position patient in sitting posture.
3.
Hemorrhage Packing with oxidized cellulose or any

absorbable hemostatic agent like gelform
Hemorrhage is the escape of blood from a
Application of hemostatic agent like
ruptured blood vessels externally or internally.
Bone wax on bone bleeding point. (bone
Arterial blood is bright red and emerges in spurts,
wax = 7 parts of yellow bee wax + 2 parts
venous blood in dark red and flows steadily, olive oil + 1 part phenol by weight) (Fig.
while damage to minor vessels may produce only 3.2)
an oozing. Rupture of major blood vessel can Cauterizing the bleeding points with chemical
lead to the loss of several litres of blood in few agent.
minutes, resulting in shock, collapse and death
if untreated. Postoperative Hemorrhage
Causes Six reasons and difficulty to stop bleeding from
extracted socket:
1. In normal patients: 1. The tissues of mouth and jaw are highly
i. Intraoperative vascular
Incision 2. Extraction leads a open wound in soft tissue
Damage caused while using various and bone
hemostatic techniques 3. Difficult to apply dressing material and proper
ii. Postoperative pressure and sealing to the intraoral sites.
primary 4. Patient tends to play with the surgical area,
reactionary therefore dislodges clot.
secondary 5. Small negative pressure is created repeatedly
2. In diseased patients: therefore dislodges clot.
Coagulation defects. 6. Salivary enzymes lyse clot.
Thrombocytopenia
Capillary abnormalities Primary Hemorrhage
Transfusion defects.
It is the persistence of bleeding even after the
Management of Intraoperative completion of surgery
Hemorrhage
Reactionary Hemorrhage
Application of pressure on bleeding areas
It is the oozing of blood from surgical site after
(Fig. 3.1)
a few minutes till hours after surgery due to
Elective ligation of the arteries
reactionary vasodilatation of vessels or
Hemostats used for catching the bleeding
dislodgement of clot which was still not matured.
point (Fig. 3.3).
Application of thrombin or Russels viper
Secondary Hemorrhage
venom, precipitate clot formation.
Packing of bony cavity with gauze It is the oozing of blood 4-10 days after surgical
pack soaked in Benzoine or white head procedure. This occurs generally due to infection
varnish present in the area of surgery.
Control of Primary Hemorrhage
Control of Secondary Hemorrhage
Management of Patient Who is Pregnant

1. Defer surgery after delivery if possible
2. Consult the patients obstetrician if surgery
cannot be delayed
3. Avoid dental radiographs unless information
about tooth roots or bone is necessary for
proper dental care. If radiographs must be
taken, use proper shielding.
4. Avoid the use of drugs with teratogenic
potential. Use local anesthetics when
anesthesia is necessary.
5. Use at least 50 percent oxygen if nitrous oxide
sedation is used
Fig. 3.1: Hemorrhage management 6. Avoid keeping the patient in the supine
on applying pressure position for long periods, to prevent vena
cava compression
7. Allow the patient to take frequent trips to
the rest room.
Dental Medications to Avoid
in Pregnant Patients
Asprin and other nonsteroidal anti-
inflammatory drugs.
Carbamazepine
Chloral hydrate
Chlordiazepoxide
Corticosteroids
Diazepam and other benzodiazepines
Diphenhydramine hydrochloride
Morphine
Nitrous oxide (if exposure is greater than
9 hr/week or O2 is less than 50%)
Fig. 3.2: Use of bone wax Pentazocine hydrochloride
Phenobarbital
Promethazine hydrochloride
Propoxyphene
Tetracycline
CARDIOPULMONARY
RESUSCITATION
Cardiopulmonary resuscitation (CPR) is a life
saving technique useful in medical emergencies,
Fig. 3.3: Suturing and applying including heart attack or drowning, in which
pressure on soft tissues someones breathing or heart beat has stopped.
Its main function is to re-establish cardiac and

pulmonary functions in emergency cases. CPR
can be administered outside hospital or in
hospital. If it is done outside hospital, then cardio-
pulmonary resuscitation is providing basic life
support, but if it is done in hospital, then basic
life support (BLS) as well as advanced care life
support (ACLS) is also given.
Objectives
The ABCs of life is maintained. Fig. 3.4: Mouth to mouth breathing
They are:-
AAirway
i. Place the patient is supine position with
head higher than the legs.
ii. Patency of the airway is checked
iii. Any obstruction in the airway by any foreign
body is removed.
iv. Patients airway is opened by a head tilt-chin
lift position.
BBreathing:
Administer mouth to mouth breathing (Fig. 3.4).
Mouth to nose breathing or mouth to airway
breathing, can also be given if mouth is seriously Fig. 3.5: Chest compression
injured or cannot be opened.
CCirculation: THERAPEUTICS IN ORAL SURGERY
i. External cardiac compressions are given to
restore blood circulation. Antibiotics
These are substances produced by micro
Compression Method organisms that either retard the growth of or
1. In case of 1 operator, 15 compressions with kill other micro-organisms at high dilution.
2 ventilations are given, which is 1 cycle. 5
Antimicrobial Agents
cycles are performed and then carotid pulse
is checked. If the pulse is absent, then CPR These are similar to antibiotics, except that they
should be resumed (Fig. 3.5). are synthetic.
2. In case of 2 operators, 5 compressions with
1 ventilation is administered. Classification of Antimicrobial Agents
According to their Mechanism of Action
Patient Evaluation
1. Drugs inhibiting cell wall synthesis:
The improvement of the patient during administ- Penicillin
ration of basic life support is evaluated by the Cephalosporins
colour of the skin and mucosa, chest size, pulse Vancomycin
rate, respiratory movements, and pupil of the Cyclosporine
eyes. Bacitracin
2. Drugs inhibiting protein synthesis: iv. Extended spectrum penicillin
Drug binds to 30s ribosomal subunit: Piperacillin
Tetracycline carbanicillin
Aminoglycoside Ticaricillin
Drug binds to 50s ribosomal subunit: v. Reverse spectrum penicillin
Chloramphenicol Imipenem
Macrolides vi. -lactamase inhibitor
3. Drugs affecting cell permeability Salbactam
Aminoglycoside Tazobactum
4. Drugs affecting DNA Gyrase:
Quinolones B. Cephalosporin
5. Drugs interfering with DNA function: 1. First generation (against gram positive cocci
Rifampicin and gram negative aerobes E.Coli, proteus)
Metronidazole i. Oral
6. Drugs interfering with DNA synthesis: cephradine
Idoxuridine cephalaxin
Acyclovir cefodroxil
7. Drugs interfering with intermediate ii. Parenteral
metabolism: cephrodine
Sulfonamides cephazoline
PAS cephalothin
Trimethoprim 2. Second generation (against first generation
Pyrimethamine organism and H.influenzae)
Ethambutol i. Oral
cefuroxime
-LACTAMASE INHIBITORS cafaclor
Classification ii. Parenteral
cefuroxime
A. Penicillin cefatetan
1. Natural penicillin cefoxitin
i. Benzyl penicillin 3. Third generation (Neisseria, E. coli,
ii. Sodium penicillin H. influenzae, Pseudomonas)
iii. Depot penicillin (procaine pen) i. Oral
2. Semisynthetic penicillin cefixine
i. Acid resistant penicillin cefprodoxine
phenoxy ethyl penicillin ii. Parenteral
phenoxy methyl penicillin ceftriaxone
ii. -lactamase resistant penicillin cefataxime
oxacillin cefaperazone
dicloxacillin 4. Fourth generation (gram positive, gram
cloxacillin negative, Pseudomonos)
iii. Broad spectrum penicillin Parenteral
Amoxycillin cefipime
Ampicillin cefpirome
Mechanism of Action SULFONAMIDES

Agent binds to cell membrane protein and Classification
inhibits cross linking between NAM and NAG 1. Short acting
and thus preventing cell wall formation of i. sulfadiazine
bacteria. Thus are bacteriocidal. (gram positive ii. sulfafurazole
bacteria has peptidoglycan, thus more 2. Intermediate acting
succeptible than gram negative). i. sulfamazole
ii. sulfamethoxazole
Indications 3. Long acting
Tonsillitis i. sulfamethoxine
Pharyngitis ii. sulfadimethoxine
Sinusitis 4. Topical
Actinomycosis i. silver sulfadiazine for burns
General infection ii. mefanide for burns
Cephalosporins are given in patients allergic iii. sulfacetamide eye drops
to penicillins iv. sulfasalazine- oral, for inflammatory bowel
disease.
Adverse Reaction
Mechanism of Action
Anaphylaxis They inhibit bacterial DHF synthase, thus
Skin rashes blocking first step in folate synthesis. They are
Serum sickness like fever bacteriostatic.
GI upset
Bone marrow depression Indications
Actinomycosis
MACROLIDES Upper respiratory tract infection (URTI)
Urinary tract infections (UTI)
Examples
Roxithromycin Adverse reactions
Azithromycin
Crystalluria
Clarithromycin
S-J syndrome
Erythromycin
Agranulocytosis
Spiramycin
Allergic skin reactions
Mechanism of action Photosensitivity
Binds to 50s ribosomal subunit, thus inhibits
protein synthesis. Cotrimoxazole
Trimethoprim + sulfamethonozole
Indications
(80 mg + 400 mg)
Similar to penicillin
(1 : 5)
Adverse reactions Both are bacteriostatic if used individually,
Nausea, vomiting, diarrhea but are bacteriocidal when used together.
Skin allergy. (drug synergism)
TETRACYCLINE (BROAD Trichomoniasis

SPECTRUM ANTIBIOTIC) Pseudomembraneous collitis
Examples Adverse Reactions
Tetracycline
Metallic taste
Doxycycline
Vomiting, headache
Minocycline
Red coloured urine
Oxytetracycline
Antabuse like reaction with alcohols
Chlortetracycline
PAIN CONTROL
Mechanism of Action
The various methods of pain control in dentistry
Binds to 30s ribosomal subunit. Thus inhibits are:-
protein synthesis. 1. Use of NSAIDs (Non steroidal anti inflam-
matory drugs)
Indications 2. Use of Opoid analgesic
3. Use of Anesthetic agents (local anesthetic,
Broad spectrum
conscious sedation, general anesthesia)
Alternate to penicillin in penicillin allergic
4. Acupuncture
patients.
5. Electric stimulation (TENS)
Adverse Reactions ANALGESIS (PAIN
Supra infections REDUCING DRUGS)
Growth retardation in children Classification
Dysgenesis in children
Hepatotoxicity for infants if given to pregnant A. Opioids:- (Rarely used
mother in dental practice)
Teratogenicity 1. Strong agonist
Nausea, vomiting, diarrhea. i. Morphine
ii. Pethedine
ANTIBIOTICS AND ANTIMICROBIAL 2. Mild to Moderate antagonist
AGENTS ACTING AGAINST i. Codeine
ANAEROBIC ORGANISM ii. Hydroxodone
3. Mixed antagonist/agonist
Examples:
i. Pentazocine
Metronidazole
ii. Tramadol
Ornidazole
4. Pure antagonist
Secnidazole
i. Naloxone
Tinidazole
ii. Naltrexone
iii. Nalorphine
Mechanism of Action
Breaks DNA helical structure and is Bacteriocidal. B. Non-steroidal Anti-inflammatory
Drugs (NSAIDs)
Indications 1. Salicylates
ANUG i. Asprin
Amoebiasis and Giardiasis ii. Sodium salicylate
2. Indoles Metabolic acidosis

i. Indomethacin Nephrotoxicity
ii. Sulindac Hepato-renal failure
3. Propionic acid Nausea, vomiting and diarrhea
i. Ibuprofen
ii. Ketoprofen Contraindications
4. Paramino phenol Gout
i. Paracetamol Renal failure
5. Pyrrole Children
i. Ketorolac Asthmatics
6. Pyrazolones Peptic ulcers.
i. Phenylbutazone
ii. Oxyphenbutazone CORTICOSTEROIDS
7. Oxicams
i. Piroxicam Classification
ii. Meloxicam 1. Short acting (Natural)
8. Fenamate i. Hydrocortisone
i. Mefanamic acid ii. Cortisone
9. Furanones 2. Intermediate acting (Synthetic)
i. Rofecoxib i. Prednisolone
ii. Celecoxib ii. Methylprednisolone
10. Sulfoanilide 3. Long acting (Synthetic)
i. Nimesulide i. Beclamethasone
11. Acetic acid ii. Betamethasone
i. Diclofenac iii. Dexamethasone
12. Alkanone 4. Inhaled
i. Nabumetone i. Beclamethasone
13. Benzoxazocine ii. Budesonide
i. Nefopan iii. Fluticasone
5. Topical
Mechanism of Action i. Hydrocortisone
Inhibits COX 1 and COX 2, thus inhibits ii. Beclamethasone
prostaglandin (PG) and TXA synthesis. iii. Betamethasone
iv. Fluticasone
Effects v. Dexamethasone
Analgesic Indications
Anti-inflammatory
1. Replacement therapy
Antipyretic
i. Acute adrenal insufficiency
Antiplatelet
ii. Addisons disease
2. Pharmacological therapy
Adverse Reactions i. Arthritis
GI upset (peptic ulceration and gastritis) Rheumatoid arthritis
Respiratory acidosis Osteoarthritis
Gout Adverse Reactions

Rheumatic arthritis
1. Mineralocorticosteroid
ii. Collagen disorder
i. Sodium and water retention
Systemic lupus erythromatosis (SLE)
ii. Edema
Discoid lupus erythromatosis (DLE)
iii. Hypokalemic alkalosis
Nephritis syndrome
iv. Progressive rise in blood pressure
iii. Allergic disorders
2. Glucocorticosteroid:
Anaphylaxis
i. Cushings syndrome
Urticaria ii. Hyperglycemia
Angioneuretic edema iii. Muscles weakness
Serum sickness iv. Susceptibility to infection
iv. Autoimmune disorders v. Delayed wound healing
Pemphigus vi. Osteoporosis
Hepatitis vii. Peptic ulceration
v. Bronchial asthma viii. Psychiatric disturbance
vi. Pulmonary edema ix. Growth retardation
vii. Skin disease x. Suspension of hypothalamopitiutary axis.
Pemphigus
S-J syndrome Contraindications
viii. Cerebral edema Peptic ulcer
Tuberculous meningitis Diabetes mellitus
Tumors Hypertension
ix. Malignancy Pregnancy
Hodgkins disease Tuberculosis and other infection
Leukemia Osteoporosis
x. Organ transplantation and skin grafting Herpes simplex infection
xi. Shock and septicemia. Psychosis
Epilepsy
Dental Indications Heart failure
Renal failure
i. Apthous ulcer
ii. Dental hypersensitivity SKELETAL MUSCLE RELAXANTS
iii. Desquamative gingivitis
iv. Oral lichen planus Classification
v. Oral pemphigus 1. Centrally acting
vi. Postextraction edema. Diazepam
vii. Pulp capping 2. Peripherally acting
viii. Pulpotomy i. Competitive blockers.
ix. TMJ arthritis a. long acting
x. Oral submucous fibrosis (OSMF) Tubocurarine
xii. Intracanal medicament Pancuronium.
b. short acting used for packing wound and bleeding

Mivocuronium sockets.
ii. Persistent depolarisers 5. Oxidized cellulose (Oxycel): These are surgical
Scoline. gauge treated with nitrogen dioxide and used
3. Directly acting to control bleeding from extracted socket.
Dantrolene. 6. Oxidized regenerated cellulose: These are
Indications modified oxygel which does not retard
epithelization.
Preanesthetic medication 7. Microfibrillar collagen hemostat: These
Status asthmaticus collagen product attracts platelets and triggers
Status epilepticus
their aggregation.
Adjuvant to electroconvulsive therapy
8. Styptics: These are substances which
precipitates surface protein without causing
Adverse Reactions
cell damage (astringent) and are used to
G.I disturbances. control capillary bleeding. Application of
Sedation large amount of styptics can cause tissue
Drowsiness
irritation and dry socket even. Commonly
Nausea, vomiting
used styptics are:-
Diarrhea
Malaise i. 5-10 percent aluminum chloride
Scoline apnea with succinyl choline ii. 20 percent ferric chloride/ferric sulphate
iii. 0.5-1 percent tannic acid
HEMOSTATICS iv. Iron substances
These are locally applied agents which causes Antibiotics Prophylaxis Regimens
control in bleeding. They are: for Infective Endocarditis
1. Adrenaline: 0.5 ml of 1: 1000 adrenaline
soaked in cotton plug is used to control Regimen Antibiotic Dosage
bleeding of the gingival and epistaxis by its
1. Standard oral Amoxicillin 2 gm 1 hour
vasoconstriction action. It causes cardiac regimen before procedure
abnormalities if absorbed systemically. 2. Alternative regimen Clindamycin 600 mg 1 hour
2. Thrombin: Prepared from human or bovine for patients allergic or before
plasma, is used as a freeze dried powder to amoxicillin, Azithromycin 500 mg
penicillin or both or 1 hour before
or freshly prepared solution. Used in cephalexin 2 g 1 hour before
hemophilia, skin grafting and neurosurgery 3. Patients unable Ampicillin 2 g I.M or I.V
but never given by injection as can cause to take oral within 30 min.
massive thrombosis and teeth. medication before procedure
4. Patients unable Clindamycin 600 mg I.V within
3. Fibrin foam: Human fibrin is extracted, dried to take oral or 30 min. before
and an artificial foam is made into strips which medications and cepazolin procedure
are used as required. allergic to penicillin 1 g I.M or I.V
within 30 min.
4. Absolute gelatin foam (gel foam): Absolute
before procedure
as powder or porous substance and is best
Emergency Drugs for the Dental Office
General Drug Group Common Examples

1. Parenteral preparations:-
i. Analgesic Morphine sulphate
ii. Anticonvulsant Diazepam, midazolam
iii. Antihistamine Diphenyldramine (Benadryl), chlorpheniramine
iv. Antipoglycemic 50 percent dextrose in water, glucagon.
v. Corticosteroid Methylprednisone (solumedral), dexamethasone (Decadron), hydrocortisone (solu-cortef).
vi. Narcotic antagonist Naloxone (Narcan)
vii. Sympathomimetic Epinephrine
viii. vagolytic Atropine.
2. Oral preparations:
i. Antihistamine Diphenhydramine (Benadryl)
ii. Antipoglycemic Candy, fruit juice. Sugar.
iii. Vasodilator Nitroglycerine (Nitrostat, nitrolingual).
3. Inhaled preparations:
i. Bronchodilator Metaproterenal (Alupent), epinephrine bitartrate (medihaler-Epi).
ii. Oxygen
iii. Respiratory stimulant Aromatic ammonia.
Drug Interactions Common in Dental Practice
No. Drug Interacting Drug Effect Seen

1. Antihistamine CNS depressants Increased drowsiness and sedation
2. Salicylates (Asprin) i. Anticoagulants (dicoumarin) Increases anticoagulant effect, thus
more bleeding
ii. Antacid Decreases asprin action
iii. Corticosteroids Increase GI bleeding
iv. Oral hypoglycemic Increases hypoglycemic effect
v. Phenytoin Increases antiepileptic effect
3. Atropine Alcohol Increases drowsiness
4. Carbamazepine Barbiturates, doxycycline, steroids. Decreases drug effect
5. Corticosteroid i. Antidiabetic drugs Increases hypoglycemia action
ii. Antihypersensitivity drug Antagonism
iii. Oral contraceptives Increases anti-inflammatory actions
6. Cotrimoxazole i. Diuretics Increases risk of thrombocytopenia
ii. Anticoagulants, antiepileptic, oral hypoglycemic Increases action of these drugs
7. Diazepam CNS depressants Increases sedation effect
8. Doxycycline i. Penicillin Decreases penicillin action
ii. Barbiturates and antiepileptic Decreases drug effect
9. Metronidazole i. Alcohol Antagonism
ii. Antiepileptic Increases phenytoin toxicity
iii. Anticoagulants Increases anticoagulant effect
iv. Barbiturates Decreases drug effect
10. Penicillin Oral contraceptives Increases bleeding
11. Tetracyclines i. Oral contraceptives Increases bleeding
ii. Oral hypoglycemic agents Increases hypoglycemic effect
iii. Methotrexate Increases methotrexate toxicity
FURTHER READING 5. Malamed SS Handbook of medical emergen-

cies in the dental office, 3rd ed, 1989.
1. Harcourt, Brace, Asia Malamed - Medical 6. Mc Carthy FM Medical emergency in dentistry,
emergencies in the dental office. 3rd ed 1982.
2. Hardman, Limbird, Gilman Goodman and 7. Peterson, Ellis, Hupp, Tucker Contemporary
Gilmans. The phar macological basis of oral and maxillofacial surgery, 4th ed 2006.
therapeutics, 10th ed. 8. Satoskar Textbook of Pharmacology.
3. KD Tripathi Essentials of medical 9. Tintinalli, Kalan, Stapczynski Emergency
pharmacology, 4th ed. medicine a comprehensive study guide, 6th ed.
4. Little, Falace, Miller, Rhodus Dental
management of the medically compromised
patients, 6th ed 2002.
Sterilization and
Infection Control
4
DEFINITIONS on tissues which are in contact with micro-

organism. These include scrubbing and
Sterilization preparing of operational site.
It is the process by which any article, surface or
media is made free from all micro-organisms Infection
either in the vegetative or in sporing state.
It is the deposition of organisms in the tissue and
Disinfection their growth resulting in a host reaction.
It is the process by which the number of viable
micro-organisms is reduced to an acceptable Cross Infection
level, but may not inactivate some viruses and Transmission of infection among patients,
bacterial spores. practitioners, practitioners family, community,
sources are suffers and carriers (patient and
Disinfectant practitioners).
It is a chemical substance which causes disinfec-
tion. CLASSIFICATION OF THE AGENTS
USED IN STERILIZATION
Cleaning
It is a process which removes visible contamina- Physical Agents
tion, but not necessary destroy microorganism.
1. Sunlight
It is done prior to sterilization and disinfection.
2. Drying
Asepsis 3. Filtration
i. Membrane filters
It is the avoidance of pathological organisms, ii. Rapid and slow sand filters
methods to prevent contamination of wound iii. Earthen and asbestos filters.
by letting only sterile objects to come in contact 4. Radiators
with the area. NO TOUCH TECHNIQUE i. Ionizing radiations
ii. Non ionizing radiations.
Antisepsis
5. Vibration
It is the procedure or application of antiseptic i. Sonic vibration
solution. This inhibits micro-organisms growth ii. Ultrasonic vibration
Sterilization and Infection Control 41
6. Heat AUTOCLAVE (STEAM UNDER

i. Dry heat PRESSURE STERILIZATION)
Red hot flame
Flaming Most commonly used method for sterilization in
Insineration dental practice. It works on the principles of a
ii. Moist heat pressure cooker, according to which when steam
Below 100C (Inspirator at 80-85C) comes in contact with a cooler surface, it converts
At 100C (Boiling water at 100C) to water giving off its latent heat which is used
Tyndilization at 100C for 20 min. for the sterilization procedure (Fig. 4.1).
Above 100C (Autoclave) Parameters Used
Chemical Agents 1. For light load of instruments:-
1. Alcohol Temperature : 250F (121C)
Ethyl alcohol Time : 15 minutes
Isopropyl alcohol Pressure : 15 lbs
Methyl alcohol 2. For wrapped instruments:-
2. Aldehyde Temperature : 273F (134C)
Formaldehyde Time : 7 minutes
Gluteraldehyde Pressure : 130 lbs
3. Dyes
Aniline
Advantages
Acryline It is a rapid and most effective procedure for
4. Halogens sterilization of cloth, surgical packs and towel
Iodide packs where other methods cannot be used.
Chloride Automated models are also available.
5. Phenol
Cresol Disadvantages
Chlorhexidine Items sensitive to high temperature cannot be
6. Gases used. This method can rust carbon steel instru-
Ethylene oxide ments and leads to coagulation of powder items.
Formaldehyde
7. Surface active agents
Cationic salts
Anionic salts
Non-ionic salts.
8. Quaternary ammonium compounds (used
to clean blood spills in hospitals)
Fumigation = Procedure for gas sterilization
of operation theatre, wards and hospitals.
For a room of 1000 cc a box of 150 gm
KMnO4 (potassium permanganate) and 280 ml
of formalin is mixed and kept. Formaldehyde
gas is released which is allowed to circulate in
the closed room for 24-72 hrs after which the
gas is allowed to escape before being used. Fig. 4.1: Autoclave
CHEMICLAVE (CHEMICAL UNDER Inaccurate calibration, lack of setting and

PRESSURE STERILIZATION) attention and addition of instrument without
restoring are common errors.
Parameters Used
BOILER (BOILING WATER AT 100C)
Temperature : 270F (131C)
Time : Half hour cycle Parameter Used
Pressure : 20 lbs Temperature : 98C-100C (at sea level)
Chemicals like ethylene oxide is used instead Time : 10 minutes
of water for this procedure, thus the risk of Boiling is not a very effective method of
rusting of carbon steel burs is reduced. But, sterilization as it does not kill spores. It is used
ethylene oxide is hazardous for certain in cases where autoclaving or other methods are
instruments and even for some patients. not being able to be used (like when sterilize
is out of order). Boiling is at elevated tempe-
DRYCLAVE rature so it is better than other disinfectants used
(DRY HEAT STERILIZATION) at room temperature. It destroys the blood
borne pathogens. Pressure cookers etc are similar
Parameters Used as it increases the temperature and creates
condition similar to that in an autoclave.
Conventional Method
Temperature : 320F (160C) Action of Disinfectants
Time : 30 minutes for individual instruments and and Antiseptics
for better result increase total time by 50 percent.
Coagulation of bacterial proteins
Alteration in the properties of bacterial cell
Short Cycle wall.
Temperature : 370-375F (210-215C) Binding of sulfhydryl groups or essential for
Time : 12 minutes (for wrapped instruments) enzyme action.
6 minutes (for unwrapped instruments) Competition with essential subtract for the
important enzymes in bacterial cell.
Advantages
Principles of Sterilization
Carbon-steel burs and instruments do not rust,
corrode or loose their temper or cutting edges All used instruments should be properly
if they are well dried before use. They usually cleaned of blood and debris before sterilization
provide larger space at low cost. Rapid cycles It is essential for the sterilization agent (heat,
are possible at high temperature. steam or gas) to be in contact with every
surface of each item to be sterilized for the
Disadvantages specified period of time at the specific
temperature.
High temperature may damage heat sensitive All sterilizing equipment must be regularly
items like rubber or plastic instruments. serviced and maintained by suitably qualified
Sterilization cycles are prolonged at low engineers.
temperature. Heavy loads, crowding and heavy The manufactures instructions should be
wrapping can deflect sterilization. They may not strictly followed for its operation and
be automatically timed. maintenance.
Sterilization and Infection Control 43
Methods of Sterilization or Disinfection of Selected Dental Instruments
Items Steam autoclave Dry heat oven Chemical sterlization

(rarely used)
1530 min. required 1-1/2 hours required
per cycle per cycle
Stainless inst. (loose), ++ ++
restorative burs.
Instruments in packs ++ + (small packs)
Instrument tray set ups, + ++
surgical or restorative (size limit)
Rustable instruments (only when coated with ++
chemical protectant)
Hand piece (autoclave) ++
Hand piece (non autoclave) + (iodophor disinfectant)
Angle attachment + +
Rubber items ++
Rag wheels ++ +
Removable prosthetics + (sodium hypochlorite)
Heat-resistant plastic ++ +
evacuators
(A) (B) (C)

Figs 4.2A to C: Draping of operator: (A) Drape is held straight before wearing; (B) First right side is
draped followed by the left; (C) The nurse tightens the drape in position
(A) Gloving right hand (B) and (C) Gloving left hand
Figs 4.3A to C: (A) The cuff of the right hand gloves is held and worn first;
(B) and (C) The left hand cuff is held followed by complete gloving of the operator
Fig. 4.4: Patient preparation
FURTHER READING 4. Daniel M Laskin Oral and maxillofacial surgery.

The biomedical and clinical basis for surgical
1. Ananthanarayan and Panikers Textbook of practice, Vol. 1.
Microbiology, 7th ed. 5. GR Seward, M Harris, DA Mc Gown Killey and
2. Black SS Disinfection, sterilization and Kays outline of oral surgery, part I, 10th ed.
preservation, 3rd ed. 6. Peterson, Ellis, Hupp and Tucker
3. Darby and Walsh Dental hygeine theory and Contemporary oral and maxillofacial surgery, 4th
practice, 2nd ed. ed. 2006.
Armamentarium and
their Usage in Oral and 5
Maxillofacial Surgery
Explorer (dental probe) (Fig. 5.1) It is used to hold swab or sponge and clean
the area of operation, to press on the tonsillar
It is long, thin double ended instrument.
bed to arrest hemorrhage and hold the
It is used for exploring and diagnostic
tongue & give anterior traction to present
purposes.
airway obstruction.
Fig. 5.1: Explorer (dental probe)
Mouth Mirror (Fig. 5.2) Fig. 5.4: Sponge holder
It has two partsthe mirror top and the

Cartridge Syringe (Figs 5.5A and B)
handle.
It is used for reflection (for better visuali- Cartridge syringe are of two types: (a) Breech
zation) and also for retraction. loading aspirating type (b) Breech loading,
self aspiring type. In cartridge syringes (metal
and plastic) anesthetic cartridges are used.
Plastic disposable syringe are available in
Fig. 5.2: Mouth mirror different sizes and contain a luer lock
screw on needle attachment but no aspiring
Dissection Forceps (Fig. 5.3) tip.
It is a straight, long forcep with a blunt nose.
It is used to hold and retract tissues during
dissection.
Fig. 5.5A: Cartridge syringe

Fig. 5.3: Dissection forceps (college type)
Sponge Holder (Fig. 5.4)

It is an instrument with long blades, expan-
ded at the ends, forming an oblong tip. Fig. 5.5B: Plastic disposable syringe
Cheatel Forceps (Fig. 5.6)

It has two lengthy, heavy square shaped
blade with slight curvature at the tip. Blades
are angulated. No ratchet at handle.
Used to hold other instruments
Fig. 5.8: Upper anterior dental extraction forceps
Root Forceps
These are forceps with blades which are
designed to embrace the roots of teeth. The
Fig. 5.6: Cheatel forceps
blades are made in a variety of widths and
lengths.
Towel Clip (Fig. 5.7)
Root forceps are used for removal of
It is like an artery forceps with ratchet. Has accessible root pieces of upper anteriors
pointed curved ends (tongue forceps)
Used to severe drape in position. Upper pre-molars Dental
Extraction Forceps (Fig. 5.9)
Beaks are slightly angulated to handle set in
an "S" curve in view for good access
Tips of both beaks are mirror image
(rounded tips)
Used for removal of whole tooth all upper
pre-molar both right and left.
Fig. 5.7: Towel clip
Upper Anterior Dental Extraction Forceps

(Fig. 5.8)
It is an instrument for the extraction of teeth
so designed as to apply forceps with the
optimum mechanical advantage of a pair of
short blades through a joint in the handles.
Beaks are parallel or in line with handle.
Tip of both beaks are mirror image (rounded
tips)
Used for removal of whole tooth all upper Fig. 5.9: Upper pre-molar
anterior both right and left. dental extraction forceps
Armamentarium and their Usage in Oral and Maxillofacial Surgery 47
Upper Pre-molar Root Extraction Forceps

(Fig. 5.10)
It is a fine tipped long shanked instrument.
Used for removal of accessible root piece of
pre-molars both right and left.
Fig. 5.12: Left upper molar dental

extraction forceps
Bayonet Forceps (upper root) (Fig. 5.13)

Root forceps for use in upper posterior teeth
in which shanks are contra angled for ease
of access.
Fig. 5.10: Upper premolar root extraction forceps
Has binangled beak, fine tipped
Both the beaks are mirror image
Right Upper Molar Dental
Used for removal of accessible root pieces
in upper molars both right and left.
Beaks are slightly angulated to handle
One of the beak tip is modified as pointed
(eagle's beak) and other tip rounded.
Used for removal of whole tooth-upper left
1st and 2nd molars.
Fig. 5.13: Bayonet forceps (upper root)
Upper Third Molar Forceps (Fig. 5.14)

Has Binangled shank or blades
Tips of the beaks are rounded and mirror
imaged.
Fig. 5.11: Right upper molar dental
extraction forceps
Left Upper Molar Dental

Beaks are slightly angulated to handle
One of the beak tip is modified as pointed
(eagle's beak) and other tip rounded.
Used for removal of whole tooth-upper left
1st and 2nd molars. Fig. 5.14: Upper third molar forceps
Root Separator (upper)- Lower Pre-molar Dental

Cow Horn Forceps (Fig. 5.15) Extraction Forceps (Fig. 5.17)
Forceps with side cutting blades Beaks almost right angled to handle
Used for splitting roots in multirooted teeth Has rounded tips, tips of both beaks are
when tooth has broken at C.E junction or mirror image
in badly decayed tooth. Has a gap between both beaks
Blade width is more than lower anterior
forcep
Used for removal of whole lower pre-molar
tooth both right and left.
Fig. 5.15: Root separator (upper)
Lower Anterior Dental Extraction Forceps

(Fig. 5.16)
Beaks right angle to handle.
Fig. 5.17: Lower pre-molar
Has rounded tips, tips of both beaks are dental extraction forceps
mirror image
Used for removal of whole tooth-lower
Lower Pre-molar Root
anteriors both right and left
Root forceps are fine tipped
Forceps (Fig. 5.18)
Used for removal of accessible root pieces It is a fine tipped, little lengthy beaked forcep
of lower anteriors Close contact between beaks when closed
Close contact between beeks when closed. Used for removal of accessible lower pre-
molar roots both right and left.
Fig. 5.16: Lower anterior dental

extraction forceps Fig. 5.18: Lower pre-molar root forceps
Lower Molar Dental Extraction Forceps Coupland's Elevator or Chisel (Fig. 5.22)
(Fig. 5.19) This is not a true chisel but a hand gauge
Beaks are almost right angled to handle made with varying widths of blade attached
Both the beaks tips are pointed (eagle's beak) to an octagonal pear shaped handle
Used for removal of whole tooth-lower Used in wedge principle mainly with first class
molars both right and left. lever or wheel and axle.
Fig. 5.19: Lower molar dental extraction forceps

Fig. 5.22: Couplands elevator or chisel
Root Separator (lower)-cow Horn
Apexo Elevators (Fig. 5.23)
(Fig. 5.20)
Straight - used in wedge with first class lever
Used for splitting lower molar roots when tooth
or wheel and axle principle.
breaks at c.e junction and roots are intact.
Angled - used in wedge with first in class lever
principle.
Fig. 5.20: Root separator (lower)
Coleman Elevator (separated blade)

(Fig. 5.21) Fig. 5.23: Apexo elevators
It is a straight elevator
Lendo Levien Elevator (Fig. 5.24)
Used in first class lever mainly with wheel and
axle. Used in first class liver- with wedge or wheel
or axle principle.
Fig. 5.21: Coleman elevator (separated blade) Fig. 5.24: Lendo levien elevator
Winter's Cross Bar Elevator (Fig. 5.25)

It is a set of paired levers with cork screw
pattern handles and various shaped points
or blades.
The blade of this instrument is triangular in
shape at end at 45 angualation to shaft.
Used in wheel and axle mainly with first class
lever principle.
Fig. 5.27: Warwick james elevator
Hospital Pattern Elevator (Fig. 5.28)

lever principle.
Fig. 5.25: Winters cross bar elevator
Cryer's Elevator (Fig. 5.26)

lever principle.
Fig. 5.28: Hospital pattern elevator
Moon's Probe (Fig. 5.29)

It is a flat, almost right angled blade with tip
Fig. 5.26: Cryers elevator blunt and half moon shaped.
Used to detach epithelial attachment.
Warwick James Elevator (Fig. 5.27)
It is a set of three instruments, used for
removing root fragments and impacted tooth.
The handles are flattened elongated and non- Fig. 5.29: Moons probe
serrated. The blades are small and smooth.
One with straight blade and two with curved Dental Mouth Prop (Fig. 5.30)
angulated.
Straight - used in first class lever mainly with It is a non-adjustable intra-oral device used
wheel and axle principle. to keep the mouth open
Angulated - used in wheel and axle mainly Used to maintain mouth opening in
with first class lever principle. prolonged surgery.
Ward Periosteal Elevator (Fig. 5.33)

Used for mucoperiosteal reflection
Fig. 5.33: Ward periosteal elevator
Fig. 5.30: Dental mouth prop.

Periosteal Elevator (Fig. 5.34)
Surgical Blades (Fig. 5.31) Used for mucoperiosteal reflection
It is designed to fit into Bard parker handle
available in numbers and shapes
No. 10- skin incision
No. 11- drainage of an abscess: excision
of fistulous tract Fig. 5.34: Periosteal elevator
No. 12- incision in palatal aspect: distal
to last molars: incision of marginal Retractors
gingivae
No. 15- incision in accessible area It is an instrument designed to displace the
(commonly used) soft tissues to improve vision, access and
afford them protection during surgical
procedures. They are divided into groups
according to the tissue concerned.
Kay's Modified Austin Retractor

(Fig. 5.35)
It is a flat bladed right angled instrument with
the end rounded other end serrated or saw
type.
Used to retract tissue gently and steadily away
Fig. 5.31: Surgical blades from operative field.
Howarth Periosteal Elevator (Fig. 5.32)

It is a hand instrument designed to strip the
mucoperiosteum from the underlying bone
following an incision
Used for mucoperiosteal reflection in pen
grasp and push or pull or pry stroke.
Fig. 5.32: Howarth periosteal elevator Fig. 5.35: Kays modified austin retractor
Kilner Skin Retractor (Fig. 5.36) Hovell Lingual Flap Retractor (Fig. 5.40)
Used to retract deeper tissues to facilitate Used to retract lingual flap of third molar
deeper dissection. during impaction.
Fig. 5.36: Kilner skin retractor
Rowe Maxillary Labial Retractor

(Fig. 5.37)
Fig. 5.40: Hovell lingual flap retractor
It is a flat blade instrument with both the ends
curved and rounded tips Ward Cheek Retractor (wisdom tooth)
Used to retract labial mucoperiosteum. (Fig. 5.41)
Used to retract both buccal flap and cheek
during lower impaction
Fig. 5.37: Rowe maxillary labial retractor
Langenbeck Retractor (Fig. 5.38)

Used to retractor deeper tissue and to
facilitate deeper dissection. Fig. 5.41: Ward cheek retractor (wisdom tooth)
Aufright Retractor (Fig. 5.42)

Used to retract deeper soft tissues to facilitate
deeper dissection
Fig. 5.38: Langenbeck retractor
Cheek Retractor (Fig. 5.39)

Used to retract angle of mouth and cheek
for orthodontic and photographic purpose.
Fig. 5.42: Aufright retractor
Jenkin's Chisel (Fig. 5.43)

It is a bone cutting instrument having a
handle and blade which is composed of two
Fig. 5.39: Cheek retractor flat surfaces, one of which is beveled to meet
the other and cutting edge is at one side. It other and cutting edge is at one side and
is used with mallet. half moon shaped (concave)
Used to cut bones Used to separate nasal septum from palatine
Used to join holes in postage stamp method. crest.
Fig. 5.47: McIndoe nasal chisel

Fig. 5.43: Jenkins chisel
Kelsey Fry Mallet (Fig. 5.48)
Gouge (Fig. 5.44) Its head is cylindrical, made of metal,
sometimes plastic or wooden faced, obtained
in various weights
Fig. 5.44: Gouge Used in pull motion.
Gillies Osteotome (Fig. 5.45)

It is a bone splitting instrument in which the
two flat surfaces of the blade are ground to Fig. 5.48: Kelsey Fry mallet
meet each other to form a wedge. Cutting
edge is in the centre. It is used with mallet Surgical Burs (Fig. 5.49)
to cleave the bone. Has a long shank with wide pitch between
Used to split the bone blades
Used to split the tooth Toller's no. 6 or 8
Rose head 4 or 8.
Fig. 5.45: Gillies osteotome
Jenkin's Gouge (Fig. 5.46)

It is an instrument similar in handle and shaft
to a chisel but having a concave round
ended, cutting blade.
Fig. 5.49: Surgical burs
Used to create round shaped window in
bone. Volcanite Burs (Fig. 5.50)
Used to trim and smoothen the sharp
margins and elevations
Fig. 5.46: Jenkins gouge
McIndoe Nasal Chisel (Fig. 5.47)

It is a bone splitting instrument having handle
and blade which is composed of two flat
surfaces one of which is beveled to meet the Fig. 5.50: Volcanite burs
Bone Rongeurs (ward: double action) Fickling Forceps (angled) (Fig. 5.54)
(Fig. 5.51) Its blades are angulated, having single
It is a double handled instrument making use toothed notch interdigitate during closure.
of the mechanical advantage of handle - Has ratchet at handle.
joint- blade ratio to apply force to cup shaped Used to remove detached bone pieces
cutting blades. Also used to remove tooth pieces
Used to remove bone by plaining action
To enlarge bony wall of cyst
To remove peripheral (projection) bone.
Fig. 5.54: Fickling forceps (angled)
Fig. 5.51: Ward rongeurs (double action)

Alli's Tissue Forceps (Fig. 5.55)
Bone Shears (Fig. 5.52) It has long beaks with 2 or 3 toothed type
tips interdigitate while closure. Ratchet
It is a similar instrument to bone rongeurs
present.
but with knife or chisel shaped blades.
Used to grasp tissue during dissection.
Used to remove bone by shearing action
Also used to remove sharp projection bone
Fig. 5.55: Allis tissue forceps
Fig. 5.52: Bone shears

Read curette (Fig. 5.56)
Bone Rasp or File (Fig. 5.53) It is a spoon shaped instrument designed to
remove soft infected tissues.
It is a double ended instrument with serrated
Used to explore the apices of sockets
cutting blades used to smooth down irregular
Also used to enucleate granuloma, soft
bone.
tissues, tumors, cysts.
Used for final trimming of the bony ridge
after gross removal with rongeur.
Used only in pull stroke.
Fig. 5.53: Bone file (alveolecting) Fig. 5.56: Read curette
Suture Needles (Figs 5.57 and 5.58)

Used to carry suture thread and to pass these
through the tissue. Available in various
shapes with either cutting or reverse cutting
or round bodied with eyes, closed or
frenched type or swaged.
Fig. 5.59A: Gillics scissors and needle holders

(No rachets)
Fig. 5.57: Suture needles Fig. 5.59B: Myo needle holder (with rachets)
Dissection Forceps (toothed)

(Figs 5.60A to C)
It is a fine bladed forceps with tooth. The
tip is used for grasping the mucosal flaps while
suturing or to hold the suture needle.
Used to pick up small detached pieces.
Fig. 5.60A: Gillics dissecting forceps (toothed)

Fig. 5.58: Suturing needles
Needle Holder
Fig. 5.60B: Lead dissecting forceps (toothed)
It is an instrument having blades, which grip
curved needles without rotation. Variations
are to be found in those with or without
ratchets. One blade perforated for end
holding of needles. Inside criss cross striation Fig. 5.60C: Adson fissure forceps
with central groove on opening. Some times
come with scissors behind the blades. Non-toothed Dissecting Forceps (Fig. 5.60D)
Gillies scissors and needle holder
It helps in suturing and cutting. Used to hold knot while removing sutures
Mayo Needle Holders (Figs 5.59A and B)

It has criss cross striated with central groove Fig. 5.60D: Non-toothed dissecting forceps
Scissors (Figs 5.61A to C)

Are of various shapes with long pointed or
round shaft with cutting edge one side.
Straight or curved.
Fig. 5.62B: Forceps (curved) crile artery
Fig. 5.62C: Fochester peah artery (Forceps)
Mosquito Artery Forceps (Fig. 5.63)

To clamp bleeding points
Figs 5.61A to C: Scissors
Artery Forceps (Figs 5.62A to C)

Has long and also medium sized blades.
Either curved or straight. Has tranverse Fig. 5.63: Mosquito artery forceps
serration on the inner aspect of blades.
Ratchets present. Lister Sinus Forceps (Fig. 5.64)
Used to clamp bleeding points
Has long blades with rounded flat tip,
To remove tooth fragments and root tips
transverse serration at the tip on inner aspect.
To hold or grasp tissues such as follicles or
No ratchets on the handle.
cyst membrane.
Used to explore the potential spaces to drain
an abscess
Fig. 5.62A: Forceps (Straight) crile artery Fig. 5.64: Lister sinus forceps
Skin Hook (Gillies) (Fig. 5.65) Higginson's Chip Syringe (Fig. 5.68)
Has fine hook set on the slender shaft of a Has a rubber bulb with nozzle, sterilizable.
delicate handle. Their main purpose is to Used for saline irrigation during bone removal
control the skin flaps when suturing. with bar.
Used to control skin flap while suturing.
Fig. 5.65: Gillies skin hook Fig. 5.68: Higginsons chip syringe
Hayton Williams Wire Twister (Fig. 5.66) Metal Head Frame (Fig. 5.69)
Has short round tipped like needle holder Has band of metal with varying design
but has transverse serrations on the inner attached to the head by screws which are
aspect of beak. Presence of ratchet in handle. inserted through short incisions, these screws
Used for twisting wires and tucking. contact inside of the skull frame is used for
the attachment of various devices, to
immobilize fracture of facial skeleton.
For example, Halo head frame, Andre
charest head frame, Crawford head frame.
Used for cranio- maxillary fixation, cranio-
mandibular fixation, and cranio-zygomatic
fixation.
Fig. 5.66: Hayton Williams wire twister
Wire Cutter (Fig. 5.67)

It is available in scissors type having short
beak with side cutting blades or cutting plier
type.
Used to cut sutural wires
Fig. 5.69: Hallow frame
Walshan's forceps (Figs 5.70A to C)

Nasal bone forceps: It is a set of two forceps
right and left. One blade of the forceps is
Fig. 5.67: Wire cutter designed to be inserted into the nasal cavity and
the other shaped to fit the outside of the Hayton-Williams Forceps (Fig. 5.72)
appropriate nasal bone.
Used to reduce mid palatine split.
Used to reduce nasal bone fracture.
Septal forceps: Have straight flat oval ended
blades, which is applied one on either side of
the nasal septum to straighten the nasal septum.
Used for nasal septal correction.
Fig. 5.72: Hayton-Williams forceps
Rowe's Modified Harrison Mandible

Holding Forceps (Fig. 5.73)
Figs. 5.70A to C: Walshans forceps Fig. 5.73: Rowes modified Harrison mandible
holding forceps
Maxillary Disimpaction Forceps (Rowe's)
(Fig. 5.71) Malar Bone Elevators (Fig. 5.74)
One blade of forcep is designed to pass into Three types of elevators named after persons
the nasal cavity and the other blade designed designed, used for elevating the depressed
to fit against the palate (padded) so that the zygoma through gillie's approach.
maxilla may be grasped and manually
disimpacted.
Used to reduce impacted or delayed Le Fort
fractures.
Fig. 5.71: Rowes maxillary disimpaction Fig. 5.74: Malar bone elevators
Collin Reverdin Needle (Fig. 5.75) Doyen Mouth Gags

It is of small size, used in children.
Obwegessor's Ramus Retractor

(Fig. 5.77)
It is similar to langenback's retractory except
that the edge of the retracting blade is forked,
forming a 'V' shaped notch so as to engage
the anterior border of the ramus.
Fig. 5.75: Collin Reverdin needle
Used to retract the soft tissues along the
anterior border of ramus.
Rowe's Zygomatic arch AWL (Fig. 5.76A)
Used for circum zygomatic suspension wiring.
Fig. 5.76A: Rowes zygomatic arch AWL

Fig. 5.77: Obwegessor ramus retractor
Kelsey Fry Bone AWL (Curved) Babcock's Tissue Holding Forceps

Used for circumferential (circumandibular) (Fig. 5.78)
wiring
The instrument has fenestrated blades
Kelsey Fry Bone AWL (straight) without teeth.
(Fig. 5.76B) It is used to hold the intestines and delicate
structure like peritoneum, fascia, appendix
Used for per alveolar wiring and enlarged lymph nodes.
Fig. 5.76B: Bone AWL
Ferusson's Mouth Gag

Fig. 5.78: Babcocks tissue holding forceps
It is a two handled adjustable jointed
instrument inserted between the jaws in order
Chin Retractor (Fig. 5.79)
to forcefully open them. They are applied
between teeth. It is a long, curve ended instrument used for
Used to increases mouth opening forcefully. retracting the chin in case of genioplasty, chin
Also used for jaw exercise after the surgery reduction, and other procedures involving
in adult. chin.
blood, flushing solution, debris, cystic fluid,

pus and secretions.
Frazier suction tip has a blade in the handle
for better control and a hole to control the
Fig. 5.79: Chin retractor suction speed.
Volkmann's Bone Scoop (Fig. 5.80)

It is a instrument similar to a curette, but the
concavity of the working edges is more
pronounced.
It is used to scrape the contents of a bony
cavity, due to cystic/tumourous lesions. Fig. 5.82: Suction
Also used to introduce graft material,
antiseptic powder into the surgical area. Corrugated Rubber Dam
Corrugated rubber drain is a sheet of rubber
with corrugations on its surface.
It is usually used as a drain following abscess
Fig. 5.80: Bone scoop drainage. Multiple holes are usually made in
the drain to prevent the drain from getting
Bone Spreader (Fig. 5.81) obstructed. The drain is inserted with one
end in the cavity and another and is left in
It has three blades that are separated by place for three to five days. It is secured to
spring action when the handles are the skin by sutures.
compressed.
It is used to separate the bony fragments after Endotracheal Tube
completion of the osteotomy cuts.
It is mainly used to check for the separation It is flexible plastic tube that is put in the
of the fragments during down fracture of the mouth and then down into the trachea.
maxilla or during sagital split osteotomy The tube is inserted under direct vision with
procedure. the help of laryngoscope. The purpose of
this tube is to ventilate the airway during
general anesthesia.
It can be cuffed and non-cuffed.
Erich's Arch Bar

It contains a thin stainless steel strip that has
Fig. 5.81: Bone spreader
hooks incorporated on it. It is malleable and
can be adapted to the contour of maxillary
Suction Tips (Fazier type) (Fig. 5.82) and mandibular arch and fixed on the teeth
with the help of wires.
These are the instruments, which are It is used to stabilize dentoalveolar fracture
introduced into the surgical field for and mandibular fractures that are to be
maintaining a clean field by sucking away treated by closed reduction.
Ryle's Nasogastric Tube Alar Retractor (Fig. 5.84)

It is a long hollow tube with one blunt end It is used for the retraction of the ala of the
with multiple openings and an open end. The nose during rhinoplasty
blunt end is passed through the nostril into
the stomach. To check the position of the
tube air is pushed into the tube with the help
of a syringe and checked in stomach with
stethoscope.
It is used to provide feeds to the patients who
cannot take oral feeds.
It is also used to provide gastric lavage post
operatively to flush out blood, fluids ingested
intraoperatively.
Fig. 5.84: Alar retractor
Foley's Self-Retaining Catheter
(Fig. 5.83) Suture Materials
It is catheter with self retaining mechanism, These are natural or synthetic materials used
which is in the balloon near its tip. At the for suturing of tissues after any procedure
other end of the catheter two tubes are or trauma.
present. The wider tube is meant for draining
the urine and the narrower communicates Ideal Properties of a Suture Material
with the balloon. Adequate strength
It is used for evacuation of bladder in long Minimal reaction
cases under general anesthesia, and also in Easy handling
unconscious patients. Good knotting
It is also used in patients with post operative Good memory
urinary retention ad non ambulatory patients
with multiple fractures. Classification of Suture Material
1. Absorbable
i. Natural
- catgut
- collagen tape
Fig. 5.83: Catheter - tensor fascia lata
ii. Synthetic
Tracheostomy Tube - dexon
- vicryl
The tube may be made of metal or portex. - PDC
The tracheostomy tube has an inner and an 2. Non absorbable
outer tube. The curvature of the tube is such i. Natural
that it does not damage the trachea. - linen
Its main function is to allow air entry through - cotton
a tracheostomy wound. - silk
ii. Synthetic Continuous suture- rapid water tight closure of

- Nylon areas is there and tension is uniformly distributed
- Dacron over the suture.
- Prolene
CATGUT
It is a natural absorbable suture material derived
from sheep intestine submucosa. The name Continuous locking suture- locking prevents
catgut is derived from an Arabic word- 'KINGUT' tightening of suture as wound closure progresses.
which is a thing used for whipping animal and
is aquired via same method as catgut.
Catgut is a multifilamentous suture material,
twisted mechanically and polished to make it
appear monofilamentous. The material is
numbered from 3-0 to 7-0 depending on its
thickness. 3-0 is the thickest and 7-0 is the Figure of '8' suture-used for closure of extracted
thinnest. socket and adaptation of the gingival papilla
3-0 and 4-0, used for intraoral suturing around the tooth
5-0 and 6-0, used for extraoral suturing
Catgut is absorbed by proteolytic degradation
and phagocytosis in about 5-7 days (which can
be altered by manufactures). Plain catgut has
poor knot properties and poor tensile strength,
thus Chromic catgut (made by addition of Horizontal mattress suture-
chromium salt at time of manufacturing) is used
to increase its tensile strength and knot
properties. It also prolongs absorption time and
reduces tissue reaction. Catgut is stored in
isopropyl alcohol which is a storage media and
also softens it. Before using the catgut, it should Continuous horizontal mattress suture-
be washed thoroughly with saline water to
prevent from causing irritation.
Types of Suturing Used in Dentistry

Interrupted suture- earliest and mostly used. Can
be used in areas of infection and loosening of Vertical mattress suture- done to close deep
one suture does not produce loosening of other wounds.
suture.
Continuous vertical mattress suture- Principles of Suturing

1. The needle holder should grasp the needle
at approximately three-fourth of the
distance from the point.
2. The needle should enter the tissue
perpendicular to the surface.
3. The needle should be passed through the
Subcuticular suture- tissue following the curve of the needle.
Anchor suture- 4. The suture should be placed at an equal
Continuous independent suture- distance (2 to 3 mm) from the incision on
both sides and at an equal depth
Types of Knot Used (Figs 5.85A to C) 5. If one tissue side is free and other fixed,
the needle should be passed from the free
to the fixed side.
Square knot
Position of holding needle and method of

holding forceps
Surgeon's knot
Insertion of needle along with curvature
Granny's knot
Position of knot-at thw side
6. If one tissue side is thinner than the other, 12. Sutures should be placed approximately
the needle should be passed from the 3 to 4 mm apart.
thinner to the thicker side. 13. Extra tissue should be excised to prevent
7. If one tissue plan is deeper than the other, 'Dog Ear' formation and other unsatisfactory
the needle should be passed from the results.
deeper to the superficial side.
8. The distance that the needle is passed into FURTHER READING
the tissue should be greater than the 1. Archer WH Oral and maxillofacial surgery,
distance from the tissue edge. 5th ed. Vol. 1.
9. The tissue should not be closed under 2. Danial M Laskin Oral and maxillofacial surgery.
tension, since they will either tear or necrose The biomedical and clinical basis for surgical
around the suture. practice, Vol. 1.
10. The suture should be tied so the tissue is 3. GR Seward, M Harris, DA Mc Gown Killey and
Kays outline of oral surgery, Part I, 10th ed.
merely approximated not blanched.
4. Gustov O Kruger Textbook of oral and
11. The knot should not be placed over the maxillofacial surgery, 6th ed.
incision line. 5. Peterson, Ellis, Hupp, Tucker Contemporary
oral and maxillofacial surgery, 4th ed, 2006.
UNIT II
ANESTHESIA
Anesthesia in Oral and
Maxillofacial Surgery 6
Anesthesia is the loss of feeling or sensation in Dendrites are conductive in nature and,
a part of or all of the body. Anesthesia may occur transmit impulses towards the nerve cell body.
as a result of injury to or disease of a nerve, The dendrites are shorter processes terminating
but the term anesthesia is mostly applied to the mostly near the nerve cell body.
technique of reducing or abolishing an
individual's sensation of pain to enable surgery Axon
to be performed. This is affected by administering The axon is the longest process of the nerve cell.
drugs (local anesthesia or general anesthesia) or This arises from axon hillock of the nerve cell
by the use of other methods like, acupuncture body and is devoid of Nissl granules. The axon
or hypnosis. To understand about these may extend for a long distance away from the
procedures one has to briefly understand about nerve cell body. The length of the longest axon
the cause and physiology of pain. is about one meter.
Nerve fibres are of two kinds:
GENERAL NERVE PHYSIOLOGY 1. Non-myelinated nerve fibres: In these fibres
The neuron is made up of three parts (Fig. 6.1): the axis cylinder is covered by a membrane
1. Nerve cell body called neurolemma. The speed of nerve
2. Dendrite and impulse conduction in these fibres is less.
3. Axon. 2. Myelinated nerve fibres (Fig 6.1): In these
fibres the axis cylinder is covered by a thick
Nerve Cell Body sheath called myelin sheath which is in turn
covered by neurolemma. The speed of
The nerve cell body is irregular in shape and, nerve impulse conduction in these fibres are
like any other cell it is constituted by a mass of more due to the saltatory (jumping) type of
cytoplasm called as neuroplasm covered by a conduction occurring in them.
cell membrane. The cytoplasm contains a large
nucleus, Nissls granules/bodies, neurofibriles, IMPULSE CONDUCTION
mitochondria and Golgi apparatus. IN A NERVE FIBRE
The nerve fibres are present at resting state before
Dendrite
any impulse reaches it. On getting excited by
The dendrites are the branched processes of the an impulse they change to depolarized state
neuron and are branched repeatedly. The which further changes to repolarised state and
dendrites have Nissl granules and neurofibrils. than back to the resting state.
Fig. 6.1: Neuron (Myelinated nerve fibre)
Resting State Repolarised State
Fig. 6.4
Fig. 6.2
After the impulse is transmitted to the adjacent
During resting state the membrane is permeable neuron, the Ca 2+ ions return back and
to K+ ions and impermeable to Na+ ions. This membrane returns to its original state by K+ ions
change of permeability causes a potential moving in and Na+ ion moving out actively. At
difference across the membrane of -70 mV to the time of depolarization no new impulse
-90 mV. (Resting potential) (Fig. 6.2). transmission can occur, this is called absolute
refractory period. Whereas the time during which
Depolarised State repolarisation is occurring only impulse with
stronger, potential can be transmitted, this is
called relative refractory period (Fig. 6.4).
Fig. 6.3 All or None Law

As any impulse reach the nerve membrane, the
This law states that in any nerve fibre impulse
acetylcholine neurotransmitter displaces Ca2+
can either be transmitted or not transmitted, the
ions from the phospholipid bimembrane, thus
strength of the impulse determines the number
making membrane freely permeable to Na+ ions
of nerve fibres getting depolarized, as threshold
without altering K+ ions permeability. This alters
potential gets crossed for more number of fibres.
the membrane potential which is transmitted
through the nerve along the whole length in non-
Pain
myelinated nerves and along the nodes in
jumping manner in myelinated nerves (saltatory It is an unpleasant emotional experience usually
conduction) (Fig. 6.3). initiated by a noxious stimulus and transmitted
Anesthesia in Oral and Maxillofacial Surgery 69
over a specialized neural network to the CNS Thalamus Hypothalamus

where it is interpreted as such. Lateral reticular
Pain has dual nature: Nucleus formation
1. Pain perception: It is a physio-anatomic
process were impulse is generated as Median reticular formation
transmitted.
2. Pain reaction: It is a psycho-physiological Dorsal root ganglion Pain
process where indivisual feels and senses
pain.
Pain Theories
1. Specific theory: Specific mediator of touch,
heat, cold and pain are present on skin and
from here specific sensory nerve takes the
impulse to specific site or pain centre in the
brain where it is interpreted.
2. Pattern theory: Pain is dependent upon
specific pattern of nerve impulse produced
by summation of sensory input within spinal
cord.
3. Gate control theory: Peripheral nerves carry
impulse from skin to CNS, larger nerves also
help in exciting or inhibing the impulse.
Descending control system modulates the
excitation of cells and tissues and thus
transmitted information about injury.
CNS
Peripheral Gate control Larger Fig. 6.5: Descending tract of fibres

nerves system nerves (transmission of pain in CNS)
Information
FACIAL NERVE NEUROLOGY
Course of the Facial Nerve
Pathways of Pain The facial nerve is attached to the brainstem by
The afferent fibres of trigeminal nerve bring two roots- motor and sensory (nervous
impulses from the orofacial region. (tooth and intermedius). The two roots are attached to lower
adjacent structures) to the semilunar ganglion. part of the lateral border of the pons just medial
From here the sensory fibres carry impulses to to the VIII cranial nerve and then reach the
the pons, where the fibres divide into ascending internal acoustic meatus.
(carry touch and pressure sign) and descending In the meatus, the motor root lies in the
(carry pain signs) (Fig. 6.5). groove of the VIII cranial nerve, with the sensory
root intervening them. Here the VII and VIII III. Terminal branches in the parotid gland:
cranial nerves are accompanied by the labyrinth i. Temporal nerve (supplies the auricularis,
vessels. frontalis, orbicularis oculi)
Within the canal, the course of the nerve is ii. Zygomatic nerve (supplies the orbicularis
divided into three parts by two bends:- oculi)
1st partjust above the vestibule iii. Buccal nerve (the upper buccal nerve
2nd partnear middle ear, above the supplies the parotid duct).
promontory iv. Mandibular nerve (supplies muscles of
3rd partbehind the promontory lower lip and chin)
The first bend is sharp; near the v. Cervical nerve (supplies the platysma)
anteriosuperior part of the promontory also
called the Genu and contains the geniculate Trigeminal Nerve Neurology
ganglion. It is the largest cranial nerve contains both
The second bend is gradual and lies in sensory and motor fibres. It is the sensory nerve
between the promontory and aditus of the ear. of the face (Fig. 6.6).
The facial nerve leaves the skull through the
stylomastoid foramen. In its extracranial course, Sensory Root
the facial nerve crosses the base of the styloid
process and enters the parotid gland. It then It arises from the semilunar ganglion. The
crosses the retromandibular vein and external ganglion forms two processesCentral and
carotid artery and behind the neck of the Peripheral. The peripheral branches to form
mandible it divides into five terminal branches ophthalmic, maxillary and mandibular division
which emerge along the parotid gland. of the trigeminal nerve. The central branches
are the sensory roots of the trigeminal nerve.
Branches of the Facial Nerve
Motor Root
I. Within the facial canal:
This is consists of fibres that arise in the motor
i. Greater petrosal nerve (supplies the
nucleus located in the pons. The filament passes
lacrimal gland and the mucosal glands of
from the pons along the medial side of semilunar
nose, palate, pharynx)
ganglion and passes below the foramen ovale
ii. Nerve to the stapedius (supplies the
and joins the mandibular division of sensory root.
stapedius muscle)
It supplies the muscles of mastication, therefore
iii. Chorda tympani (supplies the submandi-
called as masticator nerve.
bular and sublingual glands, and taste buds
of anterior 2/3 of tongue)
Mesencephalic Root
II. Extracranial:
They accompany the fibres of motor root.
i. Posterior auricular nerve (supplies the
auricularis and occipitalis)
Branches of the Trigeminal Nerve
ii. Digastric nerve (supplies posterior belly of
digastric muscle) A. Ophthalmic division
iii. Stylohyoid nerve (supplies stylohyoid 1. Lacrimal nerve (supplies the lacrimal gland
muscle). and conjunctiva).
2. Frontal nerve (supplies the frontal sinus) c. Posterior superior alveolar nerve (supplies
a. Supraorbital nerve (supplies the upper all the maxillary molars except for the
eyelid, scalp and forehead) mesiobuccal root of the maxillary 1st
b. Supratrochlear nerve (supplies the skin molar, also the upper gingiva and
of the upper eyelid, median portion of adjoining parts of the cheek).
forehead). d. Branches in the infraorbital groove:
3. Nasociliary nerve i. Middle superior alveolar nerve
a. Branches in the nasal cavity (supplies the maxillary premolars)
b. Branches in the face ii. Anterior superior alveolar nerve
c. Branches in the orbit: (supplies the incisor and canine teeth).
i. Long ciliary nerve (supplies the iris and e. Terminal branches on face:
cornea) i. Palpebral branch (supplies skin of
ii. Posterior ethmoid nerve (supplies lower eyelid).
ii. Nasal branches (supplies the skin of
posterior ethmoidal sinus and
the side of nose and nasal septum).
sphenoidal sinus).
iii. Superior labial branch (supplies the
iii. Anterior ethmoid nerve (supplies
skin of anterior part of cheek, skin of
anterior ethmoid sinus and frontal
upper lip, labial glands and mucous
sinus).
membrane of mouth).
Internal nasal nerve C. Mandibular Division
External nasal nerve (supplies the 1. Branches from the autonomic ganglia
tip of nose, ala and vestibule). associated-
B. Maxillary division: a. Submandibular ganglion
1. In the middle cranial fossa - Middle b. Otic ganglion
meningeal nerve. (supplies the dura). 2. Branches from the undivided nerve (main
2. In the pterygopalatine fossa - truck)-
a. Zygomatic nerve a. Nerous spinosus (supplies the dura
i. Zygomatico temporal nerve (supplies and the mastoid cells).
the temporal fossa region). b. Nerve to medial pterygoid (supplies
ii. Zygomatico facial nerve (supplies medial pterygoid, tensor tympani and
tensor vali palatine)
zygomatic bone, upper lip, upper part
3. Branches from the divided nerve-
of the cheek).
a. From Anterior division:
b. Pterygopalatine nerve
i. Nerve to lateral pterygoid (supplies
i. Orbital branches.
lateral pterygoid muscle).
ii. Nasal branches ii. Buccal nerve (supplies buccinator,
Posterior superior lateral nasal nerve buccal gingival of lower molars).
Medial nerve/nasopalative nerve iii. Deep temporal nerve (supplies
iii. Palatine branches lateral pterygoid and temporalis)
Greater palatine branch (supplies iv. Massetric nerve (supplies the TMJ).
hard palate and gingiva). b. From posterior Division:
Middle palatine nerve (supplies i. Auriculotemporal nerve (supplies
mucous membrane of the soft TMJ, skin of tragus, meatus and
palate). tympanic membrane).
Fig. 6.6: Branches of trigeminal nerve
ii. Lingual nerve (supplies mucous LOCAL ANESTHESIA

membrane of floor of mouth,
gingiva on lingual surface of Local anesthesia is the loss of sensation in the
mandible, and bicuspid and 1st circumscribed area of the body caused by
molar). depression of excitation in nerve ending or an
iii. Inferior Alveolar nerve (supplies all inhibition of the conduction process in the
the mandibular teeth and also the peripheral nerves.
gingiva anterior to the 1st molar).
Theories of Local Anesthesia Action
ANESTHETIC PROCEDURES
USED IN DENTISTRY 1. Acetylcholine theory: Local anesthesia
prevents acetylcholine at the synapse to alter
Conscious Unconscious
the cell permeability, thus prevents
depolarization. This theory is less accepted
No LA Conscious Deep General
medication sedation sedation anesthesia as acetylcholine is not always present at the
(LA+N2O) synapse.
2. Calcium displacement theory: Local iv. Increased amount of local anesthetic agent
anesthesia blocks calcium channel and remain in and around the nerve for longer
prevents the displacement of calcium needed duration, thus increasing the action of local
for depolarization. This theory is less accepted anesthesia.
as even in the abundance of calcium around v. There is decreased bleeding at the site of
local anesthesia acts well. administration.
3. Surface charge theory: Local anesthesia is Other effects of vasoconstrictor are:
positively charged and it binds to the outer vi. Makes the injection more painful
surface of nerve membrane, thus hindering vii. Increases the chances of subsequent local
the depolarization process. This theory is less tissue edema, necrosis and delayed wound
accepted as neutral local anesthesia also acts healing.
well. viii. Raising the B.P. and promoting arrhythmia
4. Membrane expansion theory: Local in susceptible individuals.
anesthesia solution is hydrophobic and it A local anesthetic solution with 1:1, 00,000
easily diffuses into the nerve membrane, thus adrenaline contains 0.01 mg/ml of adrenaline.
altering the nerve membrane permeability. 3. Reducing Agent: Sodium metabisulphite-
It also blocks the sodium channel inhibiting 0.5 mg/ml
depolarization. This theory best explains This agent reacts with oxygen before it
about benzocaine- neutral local anesthestic destroys the vasoconstrictor concentration.
solution. 4. Preservative: Methyl Paraben- 0.1 mg/ml
5. Specific receptor hypothesis: Local anesthesia This is added to the solution to give a shelf
solution attaches itself to specific receptors life of 2 years or more.
present at the external or internal surface of Disadvantage is it causes allergic reactions.
nerve membrane and generally near the Na+ 5. Salt: Sodium chloride- 0.9 percent
channel. This blocks the sodium channel and This is added to make the solution
inhibits depolarization. This theory is best isotonic.
accepted as receptors are found present by 6. Distill water or Ringer lactate solution: Added
chemical and electrophysiological studies. to give volume to the solution and acts as
COMPOSITION OF LOCAL a vehicle.
ANESTHETIC SOLUTION 7. Fungicide: Thymol
It is added to provide antifungal properties.
1. Local anesthetic agent: Lignocaine
hydrochloride- 2 percent (20 mg/ml) CLASSIFICATION OF LOCAL
2. Vasoconstrictor: Adrenaline- 1:80,000 to ANESTHETIC AGENT
1:2,00,000
I. According to Chemical Structure
Functions of Vasoconstrictor 1. Esters:
i. By constricting the blood vessels it decreases a. Esters of Benzoic acid
the blood flow to the site of administration. Butacaine
ii. Absorption of local anesthesia into the C.V.S Cocaine
is slowed down thereby resulting in lower Hexylcaine
anesthetic blood level. Piperacaine
iii. The lower anesthetic blood level decreases Tetracaine
the risk of L.A toxicity. Benzocaine
b. Esters of Para amino Benzoic acid:- 2. Class B (action on internal surface of nerve
Chloroprocaine membrane)
Propoxycaine Quarternary ammonium analogues of
Procaine lidocaine.
2. Amides: Scorpion venom.
Articaine 3. Class C (acting by a receptor - independent
Bupivacaine physiochemical mechanism).
Lidocaine Benzocaine
Etidocaine 4. Class D (acting by combination of receptor
Mepivacaine and receptor - independent mechanisms).
Prilocaine Most clinically useful local anesthetic
3. Quinolones: agents, for example
Centbucridine. Articaine
Lidocaine
II. According to Solubility Mepivacaine
(duration of action and potency) Prilocaine
a. Injectable:
i. Low potency, short duration of action- PHARMACOKINETIC OF LOCAL
Procaine ANESTHETIC SOLUTION
Chloroprocaine Esters are hydrolysed by esterase present in
ii. Intermediate potency and intermediate plasma and the liver. Amides are metabolized
duration of action- in the liver by N-dealkylation. Action is termi-
Lidocaine nated by removal from the site of application
Prilocaine into systemic circulation.
iii. High potency and long duration of action-
Bupivacaine REQUISITION OF AN IDEAL LOCAL
Tetracaine ANESTHETIC SOLUTION
Debucaine An ideal local anestheic solution should have:
Ropivacaine 1. Rapid onset of action.
b. Surface Anesthetics: 2. Long acting.
i. Soluble 3. Local constrictor effect
Cocaine 4. No local/systemic toxicity
Lidocaine 5. No allergic reactions
Tetracaine 6. Economical
ii. Insoluble 7. Reversible action.
Benzocaine 8. Safe.
Butylamino-beuzoate 9. Compatible PH to local tissues.
Oxethazine 10. Easy sterlizable without loosing its potency
and shelf life.
III. According to Biological Site and
Mode of Action MECHANISM OF ACTION OF LOCAL
1. Class A (action on external surface of nerve ANESTHETIC SOLUTION
membrane). Local anesthetic solution blocks voltage-gated
Biotoxins (tetrodotoxin and saxitoxin) channel in a use or frequency dependent manner.
Week base + strong acid Acidic salt

(local anesthetic solution)
Amino group Acidic salt

(Sub
mucosa)
Lipophilic molecule
Nerve sheath
(Interstitial
space)
Lipophilic molecule + H+ Hydrophilic molecule
Nerve membrane
Calcium gate blocked
Inhibits sodium transmission

and impulse conduction
Local anesthesia interferes with excitation Deep pressure

process in one of the following ways- Proprioception
Altering the basic resting potential of the nerve Skeletal muscle tone and action.
membrane
Altering the threshold potential INDICATIONS OF LOCAL
Decreasing the rate of depolarisation ANESTHESIA IN DENTISTRY
Prolonging the rate of repolarisation
1. Extraction of teeth.
2. Odontomy procedures.
EFFECT OF LOCAL 3. Alveoplasty and other surgical procedures.
ANESTHETIC SOLUTION 4. Deep cavity preparation
1. On CNS = First produces stimulation and 5. Pulpotomy and pulpectomy
then depression. Convulsion may occur due 6. Enucleation and marsuparization of cysts.
to depression of inhibitory areas. 7. Relief of denture irritation.
2. On CVS = It varies in accordance with dose. 8. Treatment of trismus
In dose of 50-100 mg used to correct 9. Neuralgias and facial pain management
ventricular arrhythmias and in moderately large 10. During radiography in patients with gagging
dose it causes decrease in myocardium 11. Treatment of facial fractures.
excitability (negative ionotrophic effect).
CONTRAINDICATIONS OF LOCAL
Loss of function occurs in the following
ANESTHESIA
order:-
Autonomic function 1. Fearful and apprehensive patients
Pain 2. Allergic patients
Cold 3. In case of acute infections
Warmth 4. Mentally retarted patients and uncoope-
Touch rative patients
5. Anatomical abnormalities Decrease pulse rate

6. Hyperthyroidism patients Decrease respiratory rate.
7. Patients with liver disorder Other effects are Cardiac Depression and
8. Patients with renal disorders Respiratory Depression.
9. Patients with cardiac disorders Preventions are:
10. Diabetic patients Aspirate before injecting
11. Patients undergoing major surgeries. Small dose injection
Use of vasoconstrictor (if not contraindicated)
COMPLICATION OF LOCAL Slow injection
ANESTHETIC SOLUTION Weak strength used.
I. Complication caused because of Treatments are:
anesthetic solution: For mild case, no treatment is required only
1. Systemic Drug reactions: discontinue drug.
i. Toxicity: It is caused due to - For moderate cases, I.V Diazepan or
Large dose Phenobarbitol sodium and oxygen inhalation
* LA solution action can be reverted by is given
phentolamine mesylate For convulsion, I.V Succinylcholine and
High concentration oxygen ventilation is given.
Direct route of administration (I.V) Cardiovascular and respiratory support given.
Rapidity of injection ii. Idiosyneracy: It is a potential, fatal response
Rapid absorption to the drug which depends on patients
Retarded metabolism (due to liver psychology and underlying pathology.
defect)
Retarded excretion (due to kidney iii. Allergy: It is caused due to antigen antibody
defect) reaction in patient previously sensitized to
Effects that are caused due to toxicity are the drug.
mainly on the central nervous system. Here Effects:
excitation is there followed by depression: Rashes, urticaria
Cerebral excitation Angioneurotic edema
Restlessness Rhinitis
Talkativeness Asthmatic symptoms
Excitement Treatment:
Convulsion Pre anesthetic evaluation should be done.
Medullary excitation Antihistamines administered.
Increase in B.P Epinephrine inhaler
Increase pulse Aminophylline given
Increase respiratory rate Oxygen inhalation given
Nausea and vomiting.
iv. Anaphylactic Reactions: Similar to
Cerebral depression
management of Hypersensitive patient as
Lethargy
discussed earlier.
Sleepiness
Unconsciousness 2. Local drug Reactions:
Medullary depression i. Infections by contaminated solutions
Decrease in B.P ii. Local irritations caused by solution.
II. Complications caused because of ii. Hematoma

needle insertion problem: iii. Facial palsy
1. Syncope - Discussed earlier.
2. Muscle trismus - It heals upon itself by time. LIGNOCAINE HYDROCHLORIDE AS
3. Pain - to avoid pain use sharp needle with LOCAL ANESTHETIC AGENT
proper technique. (infiltration should be
It is the most commonly used local anesthetic
given paraperiosteally not subperiosteally)
agent in dental practice. It represents the gold
4. Edema- It is caused due to trauma infection,
standard to which all new local anesthesias are
allergy, hemorrhage.
compared.
To prevent proper care should be taken. Chemical formula =
5. Infections- Proper care and Antibiotics should
be taken.
6. Broken needle- It can be caused due to :
i. Primary - because of unexpected patient
movement Potency = 2 (in compared to procaine)
ii. Secondary- because of size of needle, Toxicity = 2 (in compared to procaine)
redirecting needle in tissue or manufacturing PKa = 7.9
defect. pH of plain solution =6.5
7. Prolonged Anesthesia: It is caused due to pH with vasoconstrictor =5.0-5.5
contamination of local anesthesia with cold Onset of action = rapid, 2-3 minutes
solution, alcohol or other sterilizing media and Effective half life = 90 minutes.
also because of nerve impingement. Safety parameter in pregnancy = B (can be
8. Hematoma: It is caused because of improper used but some complication is noted)
technique leading to blood vessel injury or Safety parameter in lactation = S (safe to
coagulation diseases. No treatment is use)
required as it heals in 2-3 days on itself. Pharmacokinetics = Metabolised in liver by
(symptomatic relief) microsomal fixed- functional oxidases,
9. Sloughing: Sloughing of tissues takes place converted to monoethylglycerine and
because of improper technique and use of xylidide which is potentially toxic. Excreted
large amount of local anesthesia. via the kidney less than 10 percent
10. Bizzare neurological symptoms like: unchanged and more than 80 percent as
Facial palsy metabolites.
Muscular weakness Maximum recommended dose = 3.2 mg/
Temporal blindness lb or 7.0 mg /kg body weight (with vaso-
Crossed eye. constrictors) - less than 500 mg and, 2.0 mg/
Most common complications in maxillary nerve lb or 4.4 mg/kg body weight (without
blocks are: vasoconstrictors)- less than 500 mg.
i. Hematoma Formulations used for dental practice =
ii. Patient discomfort and pain 1. 2 percent lignocaine without vaso-
iii. Necrosis and ischemia of soft tissues constrictor. (lignocaine plain)
Most common complication is mandibular nerve Provides 5-10 minutes of pulpal
blocks are: anesthesia.
i. Muscle trismus Increased adverse reactions seen.
2. 2 percent lignocaine with 1: 50,000 Benzocaine and amethocaine are widely

adrenaline used.
Provides 60 minutes of pulpal and 2. Infiltration anesthesia: Here, the small
3-5 hours of soft tissue anesthesia. terminal nerve endings are flooded by local
It is used mainly for hemostosis anesthesia solution, making the area
purpose in surgery and with care in insensible to stimulus.
patients with CVS and hypothyroid Lignocaine, bupivocaine, and procaine are
diseases. widely used.
3. Two percent lignocaine with 1:1, 00,000 3. Field block: Here, anesthetic solution is
adrenaline deposited in close proximity to the large
Provides 60 minutes of pulpal and 3- terminal nerve branch. Afferent impulses are
5 hours of soft tissue anesthesia. blocked from traveling forward and area is
It is used for most dental procedures. anesthesised.
4. EMLA (Eutectic mixture of local 4. Nerve block: Here, anesthetic solution is
anesthesia)- deposited in close proximity to the main trunk
It is a mixture of lignocaine and of nerve. Afferent impulses are blocked from
prilocaine formed into an ointment traveling forward and area is anesthesised.
It is applied 60 minutes prior to insertion Nerve block can be of following kinds-
of canula, needle, anesthesing intact subperiosteal, supraperiosteal, intraosseous,
skin or under occlusive dressing. intraseptal, intrapulpal and intraligamentory.
5. Epidural anesthesia: Here, anesthetic solution
TECHNIQUE USED FOR is deposited in epidural space (between bone
ANESTHESIA IN DENTISTRY and dura meter). This technique is rarely used
1. Topical or surface anesthesia: Here, in dental practice.
anesthesia solution is applies topically to the 6. Spinal anesthesia: Here, anesthesia solution
free nerve endings thus making it incapable is deposited into the subarachnoid space.
to create impulses. It is available in form of Lignocaine, amethocaine and procaine are
solution, gel, or ointment. Lignocaine, widely used.
PROPERTIES OF SOME INDIVIDUAL LOCAL ANESTHETIC AGENTS
Drug Onset of action Duration of action Tissue Metabolism Uses

(minutes) (hours) penetration
1. Ligocaine (Amide) 2-3 1 Good Dealkylation in liver Mostly used
2. Bupivocaine (Amide) 10 3-9 Moderate Dealkylation in liver Nerve block
Endural anesthesia
Reduce post-op
pain
3. Prilocaine (Amide) 2-5 2 Moderate Dealkylation in liver Regional anesthesia
Infiltration
4. Amethocaine (Ester) 10 3 Moderate Plasma, liver hydrolysis Topical anesthesia
by esterase for eye and throat
5. Procaine (Ester) 2-6 2-3 Poor Plasma, liver hydrolysis Rarely used now,
by esterase first used anesthesia.
Local infiltration and field block are same with the periosteum. The anesthetic solution
methods and technique with only difference in is deposited so that it diffuses along side of
the site of injection. In field block the instrumen- and through the periosteum.
tation is used peripherally to the site of injection 3. Intra osseous injection- this method is utilized
and in local infiltration the instrumentation is in when other methods fail to produce adequate
the same area as the injection. analgesia. The anesthetic solution is deposited
The various methods of field block and local directly into the cancellous bone.
infiltration are: 4. Inter septal injection- in this method the
1. Sub mucosal injection- the needle is inserted needle is inserted into the thin porous
into the tissue underlying the mucous interseptal bone on either side of the tooth
membrane and the local anesthetic diffuses to be anesthetized.
in this plane. 5. Inter ligamentary injection- the needle is
2. Para periosteal injection- the needle inserted into the periodontal ligament at the
penetration is continued until contact is made mesio buccal corner of the mouth.
VARIOUS NERVE BLOCKS USED IN DENTAL PRACTICE

I. Procedures used for nerve blocks in maxilla:
Name Nerves Anestheised Areas Anesthetised Land Marks Technique Symptoms
1. Infra- -Infraorbital -Incisors, cuspid and -Infraorbital ridge -Needle is inserted -Tingling and
orbital -Anterior superior bicuspids, -Infraorbital either via bicuspid numbness of upper
nerve alveolar -mesial root of first depression approach or via lip, lower eye lid
block -Middle superior molar -Supraorbital notch central incisor and side of nose.
(Fig. 6.8) alveolar. -Bony and soft tissue -Anterior teeth approach to (subjective)
-Infra-palpebral support. -Pupils of eye infraorbitor canal -Absence of pain,
-Lateral nasal -Upper lip. where solution is sensation on
-Superior labial. -Lower eyelid. deposited. instrumentation
-Portion of nose. (objective)
2. Zygomatic -Posterior superior -Maxillary molars -Mucobuccal fold -Needle is inserted -No subjective
nerve block alveolar nerve. (except mesiobuccal -zygomatic process of via the mucosa and symptoms
or root of first molar) maxilla buccal pad of -Absence of pain
posterior -Buccal alveolar -Infratemporal premolar to reach sensation on
superior process of upper surface of maxilla the posterior area, instrumentation
alveolar molars -Anterior border and posterior to maxilla. (objective)
nerve block -Adjacent structures coronoid process of
or ramus
tuberosity -Maxillary tuberosity
block or
PSA nerve
block
(Fig. 6.7)
Contd...
Contd...
3. Naso- -Nasopalatine nerve. -Anterior portion of -Central incisors -After a preparatory -Numbness felt on
palatine hard palate -Incisive papilla in the injection, the needle is palate (subjective)
nerve block -Associated structures midline of palate. inserted at right angle -Absence of pain
to labial plate near the sensation on
crest of the papilla. instrumentation
(objective)
4. Anterior -Anterior palatine -Posterior portion of -Second and third -Needle is inserted -Numbness felt on
palatine nerve hard palate maxillary molars between second and posterior palate
nerve block -Associated structures -Midline of palate third molars about (subjective)
or greater -A line 1 cm from 1 cm from palatal -Absence of pain
palatine palatal gingival gingival margin sensation on
nerve margin to midline towards the midline. instrumentation
block. of palate. (objective)
5. Maxillary -Maxillary nerve -Maxillary teeth -In case of high -Either similar to Tingling and
nerve -Associated structures tuberosity technique PSA nerve block or numbness of upper
block. -hard and soft palate all landmarks are Anterior palatine lip, lower eye lid
-upper lip, cheek, side same as PSA nerve nerve block. and side of nose.
of nose and lower block. (subjective)
eyelid -In case of greater -Absence of pain
palatine canal sensation on
technique all instrumentation
landmarks are same (objective)
as anterior palatine
nerve block.
6. Infra- -Same as in intraoral -Same as in intraoral -Pupil of eye- -Needle is inserted -Same as in
orbital technique technique Infraorbital ridge till the infraorbital intraoral technique
nerve -Infraorbital notch foramen palpated
block -Infraorbital from extraoral
(extraoral depression landmarks and care
technique) should be taken for
(Fig. 6.9) the facial artery
and vein present.
7. Maxillary -Same as in -Same as in intraoral -Midpoint of -Needle is inserted -Same as in

nerve block intraoral technique technique zygomatic arch till 4.5 cm at the intraoral technique
(extraoral -Zygomatic notch. midpoint of
technique) -Coronoid process of zygomatic process
mandible near the depression
-Lateral pterygoid till pterygoid plate is
plate. contacted and than
the needle is pulled
and reinserted till
4.5 cm in a slight
forward and
upward direction.
Fig. 6.7: Local infiltration and posterior Fig. 6.8: Infraorbital Fig. 6.9: Infraorbital
superior alveolar nerve block nerve block nerve block
II. Procedures used for nerve blocks in mandible:

1. Classical -Inferior alveolar -Body and inferior -Mucobucccal fold - After palpating the -Tingling and
inferior nerve portion of ramus of -Anterior border of landmarks the needle numbness of lower
alveolar -Mental nerve mandible. ramus is inserted parallel to lip and tongue -if
nerve block -Incisive nerve -Mandibular teeth -external oblique occlusal plane of lingual nerve is
(Fig. 6.10) -Lingual nerve -Associated structures ridge mandibular teeth and effected
-Buccal nerve -retromolar triangle from opposite side of (subjective)
-internal oblique mouth at the level of -Absence of pain
ridge bicuspid till it sensation on
-pterygomandibular contacts bone. instrumentation
ligament (objective)
-pterygomandibular
raphae.
2. Mandi- -Same as in -Same as in classical -occlusal plane of -needle is inserted -Same as in classical
bular nerve classical inferior inferior alveolar nerve occluding teeth. with mouth closed, inferior alveolar
block (closed alveolar nerve technique -mucogingival parallel to occlusal nerve technique.
mouth technique junction of upper plane at level of
approach) molar. mucogingival
or Vazirani -anterior border of junction of maxillary
Akinosi ramus. molar to reach the
technique medial surface of
(Fig. 6.11) ramus.
3. Mandi- -Same as in -Same as in classical -anterior border of -needle is inserted -Same as in classical
bular nerve classical inferior inferior alveolar nerve ramus along a plane from inferior alveolar
block - Gow alveolar nerve technique -tendon of temporalis corner of mouth to nerve technique.
Gates technique -corner of mouth intertragic notch,
technique -intertragic notch of lateral to
(Fig. 6.12) ear pterygomandibular
-external ear depression till it
reaches to just
inferior to condyle.
Contd...
Contd...
4. Lingual -Lingual nerve -Anterior two third of -Same as in classical -same as in -Tingling and
nerve block tongue. inferior alveolar nerve inferior alveolar numbness of
-Floor of mouth block nerve block except anterior two-third
-Associated structures that it is given of tongue.
from same side of (subjective)
mouth after - Absence of pain
retracting 1 mm of sensation on
the needle. instrumentation
(objective)
5. Long -Buccal nerve -Buccal mucous -external oblique -needle is inserted -no symptoms
buccal nerve membrane ridge into buccal mucosa (subjective)
block -Mucoperosteum of -retromolar triangle just distal to third -absence of pain
mandibular molar molar sensation on
area. instrumentation
(objective)
6. Mental and -Mental nerve -Lower lip -mandible bicuspids -needle is inserted -Tingling and
incisive nerve -Incisive nerve -mucous membrane into the mucobuccal numbness of lower
block near mental foramen fold near the second lip of side.
-Incisor, cuspid and premolar (subjective)
Bicuspids of lower -absence of pain
arch sensation on
instrumentation
(objective)
7. Mandi- -Same as in classical -same as in classical -same as maxillary -same as maxillary -same as classical
bular nerve inferior alveolar inferior alveolar nerve nerve block nerve block extraoral inferior alveolar
block nerve block block -extraoral technique technique except nerve block
(extraoral that needle is inserted
technique) for 5 cm and is
redirected in upward
and slight posterior
direction.
8. M e n t a l -Same as mental and -same as mental and -Bicuspid teeth -needle is inserted -same as mental
nerve block incisive nerve block incisive nerve block -lower edge of body through a point and incisive nerve
( e x t r a o r a l (intraoral technique) (intraoral technique) of mandible coinciding the line block (intraoral
technique) -supraorbital notch drawn joining the technique)
-infraorbital notch supraorbital notch,
-pupil of eye. pupil of eye and
infraorbital notch
and a midway point
of lower border of
mandible and
gingival margin
Fig. 6.10: Inferior alveolar block Fig. 6.11: Akinosis technique Fig. 6.12: Gow gates technique
USAGE OF VARIOUS LOCAL ANESTHESIA TECHNIQUES IN DENTISTRY
Site A. Conversation B. Extraction C. Other treatment
Maxillary teeth
1. Any one incisor Labial infiltration of 1 ml. As for (A) with palatal infiltration
0.25 ml.
2. All four incisor Labial infiltration of 3 ml As for (A) with long sphenopalatine For apicoectomy the
nerve block 0.25 ml infraorbital nerve block of
1.5 ml is recommended
3. Canine Labial infiltration of1.5 ml As for (A) with palatal infiltration with palatal infiltration 0.25-
0.25 ml 0.5 ml.
4. 123 Labial infiltration of 3 ml or As for (A) with palatal infiltration 0.5

infraorbital nerve block 1.5 ml ml
with labial infiltration of 1 ml
over central incisors
5. Any one premolar Buccal infiltration of 1 ml

As for (A) with palatal infiltration of
0.25 ml
6. Any one molar Buccal infiltration of 1 ml
7. Two adjacent molars Buccal infiltration of 2 ml As for (A) with greater palatine nerve
block 0.5 ml
Mandibular teeth
1. Any one incisor Labial infiltration of 1 ml
As for (A) with lingual infiltration

0.5 ml
2. Canine Labial infiltration of 1.5 ml or
mental nerve block 1.5 ml
Contd...
Contd...
Site A. Conversation B. Extraction C. Other treatment
3. Premolars Mental nerve block 1.5 ml or Inferior dental and lingual nerve
inferior dental nerve block 1.5 block 1.5 ml with buccal infiltration
ml. 0.5 ml
4. 54321 12345 Bilateral mental nerve block As for (3) above for both sides, or
total 3 ml bilateral mental injections 1 ml.
5. Molars Inferior dental and lingual nerve

block 1.5 ml with buccal infiltration
Inferior dental nerve block 1.5
0.5 ml
6. Premolars and ml
molars
7. 12345678 Inferior dental nerve block with As for (5) and (6) above with lingual
labial infiltration over central and labial infiltration over central
incisor 1 ml incisor 0.75 ml
CONSCIOUS SEDATION DRUGS COMMONLY USED IN

In some cases local anesthesia is not sufficient CONSCIOUS SEDATION
to reduce the patient's pain and apprehension
1. Nitrous oxide (Inhalation)
and general anesthesia has its own limitations
2. Barbiturates (parenteral)
and complications. In these cases a process
3. Psycho sedative drugs (Diazepam,
called conscious sedation is practiced. Here the
chlorpromazine)
patient shows a minimally depressed level of
4. Narcotics (morphine)
consciousness with ability to independently and
continuously maintain an airway and respond
GENERAL ANESTHESIA
appropriately to physical stimulation and verbal
command. General anesthesia are drugs which produce
reversible loss of all sensation and conscious-
OBJECTIVES OF CONSCIOUS ness. The cardinal features of general anesthesia
SEDATION are:
1. Patient's mood is altered. Loss of all sensation, especially pain.
2. Patient is more cooperative. Sleep (unconsciousness) and amnesia.
3. Pain threshold is elevated. Immobility and muscle relaxation.
4. All protective reflexes are active. Abolition if reflexes.
5. Only minor deviation is there in vital signs. General anesthesia is very rarely used in
6. It can produce mild amnesia. dental practice.
STAGES OF GENERAL ANESTHESIA 4. The specific drug sensitivity of the patient.

5. The need for premedication or intra operative
1. Stage of analgesia: sedation.
pain gradually disappeares 6. The time to be allotted for the procedure.
patient is conscious and can hear and see 7. The technique or method to be user.
patient is in a dream like state 8. The choice of an anesthetic solution.
reflexes and respiration are normal. 9. The need and quantity of vasoconstrictor.
2. Stage of excitement/delirium:
patient is excited and may jump off the CLASSIFICATION OF GENERAL
table, hence it is a dangerous stage ANESTHESIA
muscle tone increases, jaws are tightly
closed 1. Inhalation anesthesia
breathing is jerky i. Gases:
vomiting, involuntary micturation or Nitrous oxide
defaecation may occure Cyclopropane
B.P. risers, pupil are dilated. ii. Volatile liquid:
3. Stage of surgical anesthesia: Halothane
Divided into 4 PLANES: Isoflurane
Plane 1: moving of eye balls Ether
Plane 2: corneal and laryngeal reflexes Methoxy flurane (chloroform)
are lost 2. Induction anesthesia:
Plane 3: dilation of pupil starts, there is Thiopentone
loss of light reflexes Methohexitone
Plane 4: paralysis pf intercostal muscles, 3. Basal anesthesia:
pupil is dilated, abdominal respiration Diazepam
seen Lorazepam
Surgery is carried out between plane 1 Midazolam
and plane 2 4. Neurolept analgesia:
4. Stage of medullary paralysis: Droperidol + Fentonyl
cessation of breathing, failure of 5. Dissociative anesthesia:
circulation, death. Ketamine
6. For short surgical procedures
PREANESTHETIC EVALUATION OF Atthesin
PATIENT 7. Others:
Propofol
A detailed preanesthetic evaluation of the patient Etomidate
should be done. This is done to determine the
following:- JORGENSON Technique- It is an IV sedation
1. The patient's physical and psychological procedure used in dental practice.
condition. The drugs used are:-
2. The need for the medical consultation. Pentobarbitol
3. The history of any previous unpleasant Mepridine
anesthetic experience. Scopolamine
PROPERTIES OF SOME INDIVIDUAL GENERAL

ANESTHETIC AGENTS USED VIA INHALATION
S.No. Effect Nitrous oxide Ether Halothane

1. Physical state Gas Volatile liquid Volatile liquid
2. Inflammability ++
3. Induction slow quick intermediate
4. Analgesia good moderate Good
5. Muscle relaxation poor poor moderate
6. Respiration little depression moderate depression moderate depression
7. Bronchial irritation + +
8. Blood pressure No change No change Decreased
9. Heart rate may increase No change Dysrhythmias
10. Hepatotoxicity ++
11. Post- op vomiting + +
12. Bone marrow depression ++
13. Metabolism Negligible Negligible 20% in liver
PROPERTIES OF SOME INDIVIDUAL GENERAL

ANESTHESIA AGENTS USED VIA IN INDUCTION
S.No. Effect Thiobarbiturates Oxyborbiturates Alkyl phenol Phencyclidine (Ketomine)

1. Respiratory system Depressed Depressed Depressed Stable
2. Cardiovascular system Depressed Depressed Depressed and Stable of increase in
hypotension heart rate and B.P
3. Pain on injection Occurs Occurs
4. Thrombophlebitis Occurs Occurs
5. CNS excitability Convulsion may Convulsion may be there
be there
6. Salivation Less Less Less High
7. Laryngeal reflexes Activated Activated Depressed Preserved in lighter plane
8. Recovery Slow somnolence Rapid and clear Rapid and clear Hallucination, nausea
and vomiting
9. Contraindications porphyria Convulsion Egg allergy Convulsion, hypertension
and heart disease
In case of DIAZEPAM sedation the correct ii. Salivation, respiratory secretions-less now
level is best explained by VERILL'S SIGN - as non irritant anesthesia are used.
30 percent eyelid ptosis, blurring of vision and iii. Cardiac arrhythmias, asystole.
slurring of speech. iv. Fall in B.P
v. Aspiration of gastric contents.
vi. Laryngospasm and asphyxia.
COMPLICATION OF GENERAL
vii. Awareness - dreadful perception and recall
ANESTHESIA of events during surgery.
1. During anesthesia viii. Delirium, convulsion
i. Respiratory depression and hypercardia. ix. Fire and explosion - rare row due to use
of non-inflammable agent.
2. After anesthesia: 2. Diazepam if given in pregnancy can cause

i. Nausea and vomiting withdrawal effects on the fetus and can cause
ii. Persisting sedation fetal abnormalities.
iii. Pneumonia, atelectasis 3. Vasoconstrictor drug felypressin (octopressin)
iv. Oxygen toxicities - liver, kidney damage. has an oxytocic effect to hasten child birth
v. Nerve palsies and can impede fetal circulation and can
vi. Emergency delirium cause fetal distress.
vii. Cognitive defects 4. The safety local anesthesia in pregnancy is
2 percent lignocaine with 1: 80,000
PREANESTHETIC MEDICATIONS adrenaline but its dose is limited to 3.6 ml
1. For local anesthesia: at each visit.
i. Barbiturates 5. Vasoconstrictor are avoided in pregnancy
Phenobarbitone (50-100 mg, I.V/I.M/ induced hypertension and preeclampsia.
P.O)
ii. Narcotics ANESTHESIA IN PEDIATRIC
Morphine sulphate (8-16 mg, I.V/I.M) PATIENTS
iii. Ataractics
1. Children are anatomically and psychologi-
Promethazine hydrochloride, an anti
cally less developed than adults.
emetic (25-50 mg, I.V/IM/P.O)
2. The dental environment, site of needle and
Diazepam, an amnesic and an anti
injection makes them apprehensive so
anxiety drug (5-15 mg, P.O/I.V/IM)
premedication or use of flavored topical
2. For general anesthesia
anesthesia is practiced.
i. Barbiturates
3. Needle size should be smaller, 1.5 cm long.
Phenobarbitone (50-100 mg, I.V/
4. Head stabilization is to be considered to
I.M/P.O)
reduce potential complications.
ii. Narcotics
5. Inferior alveolar nerve block is less
Morphine sulphate (8-16 mg, I.V/I.M)
recommended as the width of ramus is less
iii. Ataractics
leading to easy entering into parotid gland
Promethazine hydrochloride, an anti
and the primary teeth roots are resorbed thus
emetic (25-50 mg, I.V/I.M/P.O)
cutting their nerve supply.
Diazepam, an amnesic and an anti
anxiety drug (5-15 mg, P.O/I.V/I.M)
CHOICE OF ANESTHESIA
iv. Belladona derivatives
Atropine sulphate, an autonomic The choice of anesthesia for dental procedures
stabilizer (0.2-0.5 mg, I.M/I.V) depends on various factors, but chiefly on
v. Anti secretary surgical factors.
Ranitidine, a H2 blocker The surgical factors influencing the choice of
Or anesthetic technique include the aspects of the
Omeprazole, a P.P.I. patient's medical history and their anticipated
level of co-operation. Indeed these factors may
ANESTHESIA IN PREGNANCY dictate that a general anesthetic is required
1. General anesthesia is best avoided except in irrespective of the surgical task. There are a
an emergency. GA is avoided especially in variety of surgical factors that indicate the use
first and third trimester. of local or general anesthesia:
Local anesthesia is best for: 4. C Richard, Bennett Monheims local

i. Procedures taking less than 30-45 min anaesthesia and pain control in dental practice,
ii. Single operative site in the mouth 7th ed. 1990.
iii. Readily accessible areas of the mouth. 5. CS Ward Anaesthetic equipments.
6. DE Jong Local anaesthetics
General anesthesia is best for:
7. DH Roberts and JH Sowroy Local analgesia
e. Complicated procedure of unpredictable
in dentistry, 3rd ed.
duration. 8. Dionne, Phero, Backer Management of pain
f. Multiple operative sites. and anxiety in the dental office.
g. Working in areas of the mouth with difficult 9. Evers, Haegerstam Introduction to dental local
access (e.g. Surgical procedures in the anaesthesia.
palate). 10. Guyton and hall Textbook of Medical
Physiology, 9th ed.
FURTHER READING 11. James M Dell Clinical dental anaesthesia.
1. Adams, Hewitt, Rogers Emergency anaesthesia. 12. Sembulingam Textbook of Physiology
2. Allen Dental anaesthesia and analgesic (Local 13. Stanley F Malamed Handbook of Local
and general), 3rd ed. Anaesthesis, 5th ed.
3. AP Chitre Manual of local anaesthesia in 14. Stanley F Malamed Sedation, A guide to
dentistry. patient management, 4th ed.
UNIT III
EXODONTIA
Exodontia 7
Exodontia is the painless removal of whole tooth CONTRAINDICATIONS

or teeth or tooth root with minimal trauma to
All contraindications whether local or systemic,
investing tissues, so that the wound heals
can be relative or absolute depending upon the
uneventfully and with no postoperative
general condition of the patient. When the
preprosthetic problems.
contraindication is absolute, extraction should
never be done to avoid any risk to the patients,
INDICATIONS
whereas if the contraindication is relative then
1. Peridontal disease (In grade II and III extreme care must be taken before any
mobility cases). extraction is done.
2. Severe non-restorable carious lesion.
3. Pulp pathology (In case of pulpal necrosis I. Relative Contraindications
and irreversible pulpitis).
4. Cracked/broken tooth especially in the A. Local
mesiodistal direction or at the cervical line. i. Localized periapical pathology: If extraction
5. Teeth in the line of a jaw fracture. is done then infection may spread
6. Impacted or ectopically present teeth. generalized and systemically, so antibiotics
7. Supernumery teeth. should be administered before extraction.
8. Teeth involved with cysts or tumors of the ii. Presence of oral infection like Vincent's
jaw. Angina, Herpetic gingivostomatitis: It should
9. Teeth removed due to orthodontic reasons be treated first followed by extraction.
(for space gaining). iii. Acute pericoronitis: Pericoronitis should be
10. Malposed or malpositioned teeth. treated first followed by extraction of the
11. Teeth removed due to prosthetic involved tooth; otherwise bacterial infection
considerations. can descend to lower head and neck region.
12. Teeth in the direct field for radiotherapy to iv. Malignant disease such as teeth that are
the jaws may be removed prophylactically. located within an area of tumor, if removed
13. Over-retained deciduous teeth. could disseminate cells and thereby hasten
14. Teeth involved in the foci of infection. the metastatic process.
15. Teeth removed due to esthetic reasons v. Extraction of teeth in previously irradiated
(especially in severally tipped canines). jaw which may lead to osteoradionecrosis
and therefore must be done with extreme x. Psychosis: Proper precautions and drugs
precautions. Details will be discussed later should be given in neurotic and psychotic
in the chapter. patients.
B. Systemic II. Absolute Contraindication
i. Uncontrolled diabetes mellitus: Diabetic
patients are more prone to infection and A. Local
delayed wound healing. Extraction should
Teeth involved in arterio-venous malfor-
be done after proper precautionary
mations.
diagnosis and under prophylactic antibiotics.
If extraction is done, then it may lead to
ii. Cardiac disease like hypertension,
death.
congestive cardiac failure, myocardial
infarction and coronary artery diseases.
iii. Blood Dyscrasias: Anemic, hemophilic and
B. Systemic
patients with bleeding disorders should be i. Leukemia
dealt with extreme care to prevent excessive ii. Renal failure
postoperative bleeding. iii. Cirrhosis of liver
iv. Medically compromised patients: Patients iv. Cardiac failure
with debilitating diseases (as in T.B) and Note: Detailed management of the patient
poor medical history should be given suffering from systemic contraindications is
proper care and preoperative evaluation of discussed earlier in chapter, management of
these patient's general conditions is a must. medically compromised patients.
v. Addison's disease and patients on long term
steroid therapy: Hypoadrenal crisis may PRE-OPERATIVE ASSESSMENTS
occur in these patients due to increase in
the stress during the dental procedures. To Proper assessment of the conditions before any
prevent this 100 mg of hydrocortisone surgery is very important to avoid or to over-
should be prescribed prior to the procedure. come the potential complications. The assess-
vi. Fever of unexplained origin: The most ments to be done can be broadly divided into:
common cause of unexplained fevers is sub 1. Evaluation of the patient's anxiety level: Fear
acute bacterial endocarditis and extraction of the local anesthesia, injection, pain of the
in this condition may cause bacteremia, surgical procedure is to be done to decide
hence proper care should be taken. upon the procedure to follow.
vii. Nephritis: Extraction of chronically infected 2. General and medical health status of patient:
teeth often provokes an acute nephritis Evaluation to rule out the contraindications
hence before any dental procedure and to plan the precautions to be taken if
thorough investigations should be done. any.
viii. Pregnancy: Extraction should be avoided 3. Clinical evaluation:
in first and third trimester and extreme care i. Crown of the teeth:
should be taken during dental radiography - present/absent/fractured/carious that may
and drug administrations. effect the forceps application
ix. During menstruation cycle: As there is more - restorations that may weaken the tooth.
bleeding, patient is mentally and nervously - Attrition and strength of crown
not so stable. - Accessibility of tooth in the mouth.
Exodontia 93
ii. Root of the tooth: Extraction Forceps

- Size, shape, number and structure.
- Mobility, resorption, fracture and ankylosis
Classification
- Hypercementosis or other pathology. 1. Maxillary forceps:
iii. Surrounding structures: i. Maxillary anterior forceps
- Deposits around tooth ii. Maxillary premolar forceps
- Adjacent teeth's condition iii. Maxillary premolar root forceps
- Periapical disease and other pathology iv. Maxillary right molar forceps
- Mouth opening of patient v. Maxillary left molar forceps
4. Radiological evaluations: This is done mainly vi. Bayonet forceps
to confirm the clinical evaluation of the vii. Maxillary third molar forceps
crown, root and surrounding structure (Fig. viii. Maxillary cowhorn forceps
7.1). 2. Mandibular forceps:
i. Mandibular anterior forceps
ii. Mandibular premolar forceps
iii. Mandibular premolar root forceps
iv. Mandibular molar forceps
v. Mandibular cowhorn forceps.
Details about the forceps are discussed earlier
in the chapter of "Armamentarium used in oral
and maxillofacial surgery".
Principles for the use of Forceps

Fig. 7.1: Parts of the tooth to be
Forceps are used for two purposes:
assessed radiographically
1. Expansion of bony socket
2. Removal of tooth from socket
ARMAMENTARIUM REQUIRED
Five types of motions are used to expand
FOR EXODONTIA the socket and luxate the teeth:-
For an uncomplicated extraction we mainly need 1. Apical pressure to expand bony socket and
the extraction forceps and elevators. In surgical to displace the centre of tooth rotation,
extraction (Trans-alveolar) the instruments apically.
needed, except extraction forceps and elevators 2. Buccal force to expand the buccal crestal
are: bone.
1. Scalped handle, size 3 3. Lingual force to expand the lingual crestal
2. B.P Blade, no. 15 bone.
3. Check and tongue retractors 4. Rotational force to cause internal expansion
4. Dental hand piece and burs of tooth socket. This is particularly useful for
5. Chisel and mallet tooth with single conical root.
6. Bone rongeurs and bone files 5. Tractional force, which is applied at the last
7. Artery forceps and is gentle to deliver the tooth from the
8. Syringe socket after adequate bony expansion is
9. Suction tip achieved.
10. Toothed dissection forceps
11. Suture needle, needle holder, suture General Rules of Forceps Use
material and scissors Correct forceps selection for particular tooth
12. Mouth props. Grasp forceps with palm as far from beak
Long axis of forceps beak should be parallel Indications for Use of Elevators
to long axis of tooth.
1. It is used to luxate and remove teeth which
Forceps should hold the tooth without
cannot be engaged by the beaks of the
injuring the adjacent tooth and structures as
forceps such as impactions, malposed teeth,
apical as possible, the root surface.
extensively decayed tooth and anteriorly
drifted teeth.
2. It is used to reflect mucoperiosteal
membrane.
3. It is used to remove roots, fractured or
carious.
4. It is used to loosen teeth prior to the
application of forceps.
5. It is used to split teeth which have had grooves
cut in them.
6. It is also used to remove intraradicular bone.
Precaution to be followed
in using Elevators
(A) Correct (B) Incorrect a. We should never use the adjacent tooth as
Fig. 7.2: Principle of forcep application a fulcrum since this will damage or even
(Apply apically) luxated the adjacent tooth.
b. We should always use finger guard to protect
Elevators the patient tissue since slipping of the
instrument point into the soft tissue might
Classification cause perforation of blood vessels and
I. According to use: nerves.
1. Elevators designed to remove the entire teeth c. The forces applied through the instrument
2. Elevators designed to remove roots broken should be under control; failing to do so
off at the gingival line. would cause fracture of the maxilla, mandible
3. Elevators designed to remove root broken or the alveolar process.
off halfway to the apex d. The instrument tip should deliver the force
4. Elevators designed to remove the apical third in the correct direction to avoid the accidental
of the root forcing of the tooth into maxillary sinus.
5. Elevators designed to reflect the
mucoperiosteum (periosteal elevators) Principles for the Use of Elevators
before forceps or extracting elevators are These are:
used. i. Lever principle: Mostly used in elevators is
II. According to form: lever of 1st order where fulcrum is in
1. Straight elevators between effort and resistance. The
2. Angular elevators mechanical advantage is 3 and it depends
3. Cross bar elevators (where handle is at right on the distance of the load and resistance
angle to the shank). from fulcrum. We should increase the
Exodontia 95
Fig. 7.3: Lever principle
distance of effort from fulcrum to get more

advantage (Fig. 7.3).
ii. Wedge principle: It is used either alone or
along with lever principle. Here the elevator
is forced between the root of tooth and the
investing bony tissue parallel to the root.
Mechanical advantage is 2 to 5 (Fig. 7.4). Fig. 7.5: Wheel and axle principle
2. Transalveolar technique: This technique is

used when roots of the tooth cannot be
approached and gripped using the forceps
technique. Here, the bone is removed from
around the roots. Thus, it is also called
'Surgical technique' or 'Open method of
extraction'.
Rubber Band Extraction is done in case
Fig. 7.4: Wedge principle
of extraction in patients with bleeding
iii. Wheel and Axle principle: It is actually a disorders.
modification of lever principle and is used
either in combination with lever or wedge PRINCIPLES OF EXODONTIA
principle. Mechanical advantage gained is
4.6 (Fig. 7.5). 1. Applying displacing force to a tooth or root:
This is done either directly by using a
TECHNIQUE FOR EXTRACTION forcep or indirectly via a fulcrum using an
OF TOOTH elevator.
There are mainly two techniques used for 2. Expansion of the socket: This is done to
extraction of teeth: make the surrounding bone loose to facilitate
1. Intra alveolar technique: This technique relies easy removal of tooth.
on the ability to gain sufficient grip on the 3. Removal of bone surrounding the root: This
root of the tooth by forcing the blades of is done in cases where the expansion of bone
the instrument into the periodontal space is not possible.
between the root and the alveolar bone. 4. Sectioning the tooth: This is done in extreme
Thus, it is also called 'Forcep technique' or cases where the tooth is not being delivered
'Closed method of extraction'. otherwise.
PATIENTS AND also it helps in getting better purchase on the

OPERATOR'S POSITION tooth.
Good access and ease of extraction is the primary The sequence of extraction is:
goal in positioning both the patient and the - Third molar
operator. There are some recommended - Second molar
positions of the patient and the operator which - Second premolar
provides maximum accessibility and mechanical - First molar
effectiveness for extraction. These are: - First premolar
- Lateral incisor
Sl. Tooth to be Patient Height of Operator's
No. extracted position dental chair position
- Canine
- Central incisor.
1. Maxillary Upright or Target tooth At right side
anterior supine or at shoulder of patient Intraalveolar Technique of Extraction
teeth semi recum- height of and in the
bent position operator or front of the Steps of Intraalveolar Extraction
2. Maxillary Supine or lean patient patient
posterior semi recum- back a little 1. Detaching gingival attachment around
teeth bent position. and operator cervical part of tooth using a periosteal
stand slightly
elevator, Moon's probe, Woodson's elevator
further away
(toward's or B.P blade.
patient's feet) 2. Luxating of the tooth by using a forceps or
3. Mandibular Upright or Target tooth elevator
left tooth supine or at level of 3. Adapting forceps as apical as possible and
(third semi recum- operator's along the long axis of the tooth.
quadrant) bent position elbow
4. Lifting the tooth with slight tractional force,
4. Mandibular At right side don't pull the tooth.
right tooth of patient
5. Debriding the socket. Applying pressure using
(fourth and slight
quadrant) behind gauge and postoperative care and instruction
to patient.
ORDER OF EXTRACTION OF TEETH Direction of application of force and
In case of multiple extractions there are certain movement for individual teeth:
rules to be followed for the order of extraction. Sl. Tooth in Root pattern Movement
These are: No. maxilla
Maxillary tooth should be extracted before 1. Central incisor Conical, circular Rotation
the mandibular tooth as maxilla gets cross-section
anesthetized easily and also prevents the fall 2. Lateral incisor Oval cross-section, Buccal + gentle
of fractured crown, debris, or restorations flattened mesio rotation
distally
into the otherwise open extracted mandibular 3. Canine Long thin root, Buccal
socket. triangular cross-
Posterior tooth should be extracted before section
anterior tooth as post extracted blood gets 4. First premolar Two thin root, Wiggle and pull,
very fragile, only tooth in
collected in the posterior region which does buccal and palatal mouth to
not alter the visibility of the anterior region. pull out.
First molars and canine should be extracted 5. Second premolar One generally Buccal
after the extraction of the adjacent tooth as strong root
these tooth are the bony pillars of face and Contd...
Exodontia 97
Contd...
Sl. Tooth in Root pattern Movement
No. maxilla
6. First molar Two thin buccal Buccal

roots and one predominantly
strong palatal root, + Disto-buccal
three roots diverge twist to deliver.
markedly
7. Second molar Normally three roots Buccal +Disto-
as in first molar buccal twist
8. Third molar Roots are variable Buccal +Disto-
buccal twist.
Sl. Tooth in Root pattern Movement

No. mandible
1. Central incisor+ Thin oval cross- Bucco-lingual
Lateral incisor section, flattened
Fig. 7.7: Removal of maxillary first premolar
mesio-distally
2. Canine Long thin root- Bucco-lingual
triangular cross-
section. fractured at the cervical region if forcep is applied
3. First and second Round cross- Rotation at tooth surface, it will lead to breakage of tooth.
premolar section
4. First molar Two mesial root Bucco-lingual
In these cases alveolar application of forceps is
and one distal root. +Figure of '8' done. Here, the beaks of the forceps are applied
5. Second molar Normally as Lingual-Buccal a little above the edge of the alveolar process.
for first molar + Figure of '8' This enables easy removal of tooth without its
6. Third molar Root pattern Lingual +
breakage.
very variable. Figure of '8'
Transalveolar Technique of Extraction
Indications of Transalveolar Extractions

1. Any tooth that is resistant to normal intra-
alveolar extraction
2. Retained roots or teeth with severe carious
destruction that cannot be grasped with
forceps or delivered by an elevator.
3. Impacted teeth
4. Sclerosed, dense and unyielding bone which
is resistant to expansion.
5. Hypercementosis and ankylosed teeth.
6. Teeth with anatomic anomalies like
dilacerations.
Fig. 7.6: Removal of maxillary canine 7. Teeth with multiple or unfavorable roots.
8. Any tooth or root close to important
In certain cases as in case of extraction of structures like maxillary sinus, Mandibular
brittle tooth or tooth with cervical caries or tooth canal.
9. For pre-prosthetic adjustment of bone

contour in preparation for denture, bridges
or dental implants.
Advantages of Transalveolar
Extractions
1. Increased visibility and accessibility of the
operating area. Fig. 7.8: One-sided flap
2. Reduced undue laceration of the adjoining
tissues.
3. Prevents fear of tooth breakage
4. Reduces postoperative complications
Steps of Transalveolar Extractions

1. Administration of proper anesthesia
2. Making the incision and raising the proper
mucoperiosteal flap
Fig. 7.9: Two-sided flap
3. Removal of the buccal bony plate
4. Division of tooth, if required
5. Delivery of the tooth and root
6. Control of hemorrhage
7. Alveoplasty and other tissue filing, if required
8. Debriding and toilet of socket with saline
9. Suturing of flap and post operative care.
Principles of Flap Design

1. Shape of flap: A flap can be one sided, two-
sided or three- sided depending on the case
Fig. 7.10: Three sided flap
and the operator (Figs 7.8 to 7.10).
2. Access: Flap should be large enough to
7. Ease of closure: Flap should include all the
permit clean access to operation site without tissues like the whole inter dental papilla so
any tissue tear. that the replacement of flap should not alter
3. Blood supply: The base of the flap should
the anatomy.
be large enough to provide proper blood
8. Closure of an oro-antral communication: If
supply
there is a risk of oro-antral communication
4. Avoid vital structures: Important structures
than the flap should be sufficient to be able
like mental nerve should be taken care of.
to close it.
5. Extending flaps: Flap should be planned
properly to include all defects and properly REMOVAL OF THE BUCCAL
fulfill the need.
BONY PLATE
6. Suture over bone: The flap margins should
be over sound bony structure after the The buccal bony plate is removed to expose the
removal of the bone. tooth and provide a clear path of exit and a
Exodontia 99
suitable point of application of elevator. This is and adjacent vital structure can be there, then
done either by rotary cutting instruments the root tip can be considered to be left back.
(tungsten carbide burs or sharp stainless steel In these cases the patient should be informed
burs) along with a coolant to reduce the heat and routine examination for any complication
and wash away the debris or using a chisel or should be done.
gouge (hard instrument). The use of rotary
instrument is preferred by most dentists as this
method cuts bone more perdictably and
efficiently. Bone can to removal either, by simply
shaving down with a large bur or else a block
of bone is outline using a smaller bur and the
whole piece is then dislodged (postage stamp
method) (Fig. 7.11).
Fig. 7.12: Open window approach

for removal of root fragments
Extraction of Deciduous Teeth

Generally the extraction of deciduous teeth is
easier but it may have the following difficulties:
Fig. 7.11: PostageStamp method of bone removal 1. The underlying developing permanent tooth:
The blades of the elevator should not damage
Removal of Small Root the erupting permanent tooth.
Fragments and Root Tip 2. Fragility of deciduous roots: There may be
some root fragments of the fragile resorbing
The removal of small root fragment should be deciduous root left behind in the socket. This
tried first by closed method, using root forceps, should be left behind to prevent damage to
shoehorn elevator or root tip pick. If this is not the permanent tooth while removing them.
successful due to deep embedding of the root 3. Carious crown: In case of carious destruction
fragment or any other pathosis like hyper- of the deciduous tooth, the application of
cementosis or ankylosis then open method forceps becomes very difficult. In these cases
should be considered. Open method for removal elevator or retraction of the gingival tissues
of small root fragment can be either done by is needed.
the traditional way or by open window 4. Restricted access: Limited opening of a child's
approach where a small hole to drilled by a bur mouth causes the problems, so the use of
at the apex of the root which enables its pushing mouth props can be considered.
by a straight elevator (Fig. 7.12).
In certain cases where the root tip is smaller POST-OPERATIVE INSTRUCTIONS
than 5 mm and is embedded deep to be
removed by closed method and if open method 1. Patient should be asked to bite upon the
is considered then excess damage to the tissues gauze piece for about half-an-hour to
prevent primary hemorrhage and produce COMPLICATIONS OF EXODONTIA

clotting.
Complications of exodontia are studied under
2. After removing the gauze piece, patient
two headings:
should not probe the socket with the tongue
and asked not to suck the wound 1. Operative complications:
3. Immediately, they should have something a. Fracture of tooth
cold, to decrease the post-operative pain b. Injury to the adjacent teeth
as cold causes vasoconstriction c. Extraction of the wrong tooth.
4. Vigorous rinsing should be avoided d. Fracture of the bony structures like
5. Patient is asked to rest in a semi reclining alveolar bone and tuberosity.
position with two or three pillows under e. Perforation of the maxillary antrum.
head and avoid any sort of physical exertion f. Root displaced into the maxillary antrum
6. Patient should refrain from smoking for the g. Root displaced into the submandibular
first 24 hrs as nicotine delays wound healing space
7. A cold liquid diet for first 24 hrs should be h. Soft tissue laceration
followed by semi-solid food till such time i. Injury to the nerve bundles, inferior
the patient finds it difficult to masticate the alveolar nerve.
normal food. Patient should not have j. Hemorrhage
anything hot and should not chew from the k. Subcutaneous emphysema
operative site. (as hot will cause vasodi- l. Trauma to the temperomandibular joint.
latation and will ooze bleeding). m. Thermal injury to the tissues
8. Patient should refrain from brushing, but n. Vasovagal syncope due to apprehension
from next day, brushing is done to maintain o. Complications related to local anesthesia
oral hygiene. 2. Post-operative complications:
9. Mild antiseptic mouthwash or warm saline a. Post-operative hemorrhage
mouth rinses, 24 hours post-operatively b. Post-operative pain
facilitates healing and helps in cleansing the c. Ecchymosis and hematoma.
wound and minimize trimus. d. Post-operative edma and swelling
10. In case the extraction was complicated or e. Alveolar osteitis
massive retraction of soft tissue was done, f. Post-operative infections
local cold applications are recommended g. Septic periostitis
in intermittent and prolonged use. 1. Operative complications: These are those
11. Analgesics and anti-inflammatory agents complications that arise during the course of
administered to reduce post-operative pain extraction. They are:
and swelling. a. Fracture of the tooth:
12. The antibiotics, if started pre operatively are Causes of tooth fracture are:
required to be continued for 3-5 days post - Injudicious use of force for luxating the
operatively. teeth.
13. The operative site and surrounding - Improper application of forceps
structures may remain anesthetized for few - Wrong instruments used
hours, hence patient is advised not to bite - Teeth with very large filling
lip or cheek if order to prevent ulceration - Teeth that have become brittle because
of the region. it has been non-vital since long.
Exodontia 101
- Unfavorable root conditions like Management: The condition is generally

dilacerated roots, hypercementosed or treated by composite restoration or capping
additional root. the fractured tooth with or without
- Locked, flaring, bulbuos or very thin endodontic treatment as the condition
roots. demands. If the fracture is from the cervical
- When the surrounding bone is excessively line or below then the tooth has to be
dense because of condensing osteitis or extracted.
due to lone standing tooth for a long c. Extraction of the wrong tooth: Extraction of
period. the wrong tooth occurs due to the fault of
- Normal tooth may also fracture if wrong the operator and usually occurs in orthodon-
movements are applied. tic extractions. To prevent this, use a marker
E.g.; jerking a tooth, pulling in wrong pencil and mark the tooth to be extracted.
direction or twisting unreasonably. Management: Replant the tooth in the socket
- Single beak technique is preferred in these immediately and treatment in similar to an
cases. avulsed tooth (discussed earlier in this
- Management of these conditions are chapter).
discussed earlier d. Fracture of the bony structures: Fracture of
b. Injuries to the adjacent teeth: the alveolus takes place during Mandibular
There can be: and maxillary extractions and fracture of the
i. Loosening maxillary tuberosity takes place during
ii. Avulsion or maxillary extractions.
iii. Fracture, of the adjacent teeth during Fracture of the maxillary tuberosity takes
the course of extraction place during extraction of 2nd and 3rd molar,
i. Loosening of the adjacent teeth is caused due due to ankylosis of the tooth, whereas fracture
to the fault of the operator by using a wrong of the alveolus takes place due to injudicious
instrument (instrument should be narrower use of instrument by closed method of
than the mesiodistal width of the tooth to extraction.
be extracted). Management: Alveolar fracture is treated by
Management: If the loosening is less i.e. grade intermaxillary fixation and in severe
I then no treatment is required. Only patient conditions it is treated similarly as that of
is asked to take soft diet. Mandibular fractures.
If the loosening is severe, then splint the Tuberosity fracture is treated by splinting the
tooth to the adjacent tooth by arch bars, for tooth to maxillary tuberosity by arch bars or
2-4 weeks. in cases of acutely involved tooth, it is
ii. Avulsion of the adjacent tooth occurs mainly separated from the bone and the area is
due to the injurious use of instruments. closed by vertical mattress suture.
Management: Immediate reimplantation of e. Perforation of the maxillary sinus: Perforation
the tooth into the socket and stabilization with of the maxillary sinus occur during the course
arch bars followed by endodontic therapy. of extraction where the length of the roots
iii. Fracture of the adjacent tooth occurs due to of the maxillary bicuspids and molars are
slipping of the forceps due to improper rest invariably long or if the periapical bone is
and grasp. This fracture generally occurs to destroyed due to infection or due to
the tooth of the opposite arch. injudicious use of instrument.
Management: Treatment of perforation of pushing the floor of the mouth upwards or

sinus is discussed later in the chapter of by surgically reflecting the lingual flap to reach
maxillary sinus. the submandibular space.
f. Roots displaced into the maxillary antrum: h. Soft tissue lacerations: Gingival and mucosal
Root displacement into the sinus occurs while lacerations occur due to forceful and
removing bicuspids and molar due to improper instrumentation, such as improper
destruction of the apical bone, due to support of elevators while luxating the tooth.
periapical disease or due to injudicious use Lacerations are of the following types:
of instrument. i. Puncture wound of the soft tissue (due
The root might be pushed into the: to elevator slip)
i. Buccal cortical plate and outer cortex ii. Stretching or abrasion injury at the corner
ii. Lie between the wall and lining of the of the mouth and lip
maxillary sinus, without causing a breach iii. Tearing of the mucosal flap due to excess
in the sinus. stretching of the inadequately reflected
iii. Root piece lying in the maxillary sinus. flap edges to gain visibility.
Management: Irregular tissue margins are
Root fragment present in the maxillary sinus trimmed and approximated with the help of
should be ascertained by taking an Intra oral sutures and control of bleeding is done
periapical radiograph or an occlusal followed by a dose of prophylactic antibiotics.
radiograph. Probing of the socket or irrigating i. Injury to the nerve bundles: The following
should be avoided to prevent pushing of root branches of the trigeminal nerve are at risk
piece more superiorly and spread of during tooth extraction.
infection. - The mental nerve
Management: If the root fragment is present - The inferior dental nerve (as the nerve
in positions (i) and (ii), then conservative lies close to the roots of the lower third
approach is indicated otherwise surgical molar, the tooth roots are curved around
procedure- Cald Well Luc operation is done. the canal or grooved by it).
The details of the surgical procedure are - The lingual nerve (course close to lower
discussed in the chapter of maxillary sinus. third molar, often in contact with the
Conservative approach for the removal of lingual periosteum).
the root piece is best done by reflecting the Nerve damage during extractions can
flap and removing the root piece. lead to parathesia or anesthesia of the
Other ways are: affected area.
- Blowing the nose Management: No treatment done, observe
- Irrigation of the socket for 6 weeks to 6 months. Even after 6 months
- Use of ribbon gauze if there is no sensation then surgical nerve
g. Root displaced into the submandibular space: decompression or nerve grafting is done.
It is a very uncommon complication and j. Hemorrhage: Discussed earlier in the chapter
occurs while removing fragments of 2nd and of the 'management of medically compro-
3rd Mandibular molars especially when the mised people'.
lingual cortical plate is damaged due to some k. Subcutaneous Emphysema: It is caused due
periapical disease. to:
Management: The root fragment is retrieved - the use of air driven instrument during
either via a conservative approach by surgery
Exodontia 103
- the use of pressurized spray to dry the b. Postoperative pain: Patient usually
socket experience postoperative pain after
There is immediate swelling and on surgical procedures such as tooth
palpation there is crackling sensation present. extraction due to the amount of operative
Management: Proper prevention and care trauma caused. The lesser the trauma, the
should be taken and it is a self healing less the postoperative pain experienced
condition. by the patient. If pain is present after
l. Trauma to the Temperomandibular joint: TMJ 2-3 days, then there is secondary infection
trauma or arthritis occurs during the present.
extraction of the lower teeth without the Management: In mild to moderate pain
support to the mandible. analgesics should be administered and
Stabilizing the mandible by the operator's instructed to be taken before the effect
left hand or using bite blocks prevents the of the local anesthesia subsides. This
forces of the dental forceps to be transferred prevents the intense, sharp pain after local
totally to the mandible, causing damage to anesthesia subsides.
the capsules and ligaments to the joint. In severe pain, narcotic analgesics can also
Management: Analgesics should be be administered.
administered to relieve pain and hot c. Ecchymosis and hematoma: Ecchymosis
fermentation packs are given for relief. is a bruise, and initially bluish-black mark
m. Thermal injury: Injury to the soft tissues (lip, on the skin, resulting from the release of
cheek, mucosa) and/or the bone can be blood into the tissues either through
caused by the heat generated from rotary injury or through spontaneous bleeding
instruments by use of improper coolant or from the blood vessels, during surgical
excessive speed. A 10 rise in temperature procedures.
can destroy the osteocytes in bone. Hematoma is an accumulation of
Management: Proper coolant and speed blood within the tissues that clots to form
management should be instituted. a solid swelling. Injury to blood vessels
Application of emollient on the tissue leads to hematoma formation.
provides some relief. Management: Patient should be instruc-
n. Vasovagal syncope: This is the transient loss ted to give cold packs on the affected area
of sensation caused due to the stress and for 24 hours, followed by hot pack.
apprehension in the patient. The details and d. Postoperative edema and swelling: Some
management has taken discussed earlier in degree of swelling is to be expected after
the chapter of management of medical any surgical procedure, and greater the
emergencies. amount of operative trauma, greater will
o. Complications related to local anesthesia: The be the swelling. It mainly occurs during
various complications caused due to local transalveolar method of extraction in the
anaesthesia and its procedure has been first 24-48 hrs.
discussed earlier in the chapter of anesthesia Management: Immediately after surgery,
in oral and maxillofacial surgery. cold packs are applied to prevent swelling.
Careful instrumentation and handling of
2. Postoperative complications: the tissues during surgery minimizes post
a. Postoperative hemorrhage: Details are operative edema. Anti-inflammatory
described earlier in management of agents are administered to reduce
medical emergencies. swelling.
e. Dry socket/Alveolar osteitis: It is also Birn's Hypothesis

known as fibrinolytic alveolitis, localized
Trauma and infection
osteitis alveolalgia, alveolar osteomyelitis,

and postoperative osteitis.
Inflammation of bone marrow
It is a focal osteomyelitis in which the

blood clot has disintegrated or been lost
Release of tissue activator
with the production of foul odour and

severe pain of thrombing type, but no
Plasminogen in clot gets converted to
suppuration.
plasmin (fibrinolytic agent)

Clot is displaced and kinins are released
from kininogen (from the clot)

Pain
Mechanism
There is destruction of clot by proteolytic enzymes
produced by bacteria or by local fibrinolytic
activity. These fibrinolytic substances are
produced from traumatized oral tissues and
alveolar bone. Clot lysis occurs by 2 mechanisms:
i. Plasminogen dependent- Tissue activators
Fig. 7.13: Clinical views of dry socket after released from the damaged bone convert
mandibular third molar removal (not seen) plaminogen to plamin causing breakdown
(For color version see plate1) of the blood clot.
Cause: It causes is not known/obscure. ii. Plasminogen independent- this is due to
But few assumed etiological factors are: anaerobic micro-organisms.
- Preexisting infection
- Trauma to the bone and soft tissue
Features
during extraction Intense, throbbing pain and radiating from
- Decreased bleeding in the wound due the socket
to vasoconstrictor in the local Blood clot is lost from the socket
anesthesia. Clot appears dirty grey, ultimately leaving a
- Infection entering the socket following grey or grayish yellow bony socket which is
extraction deprived of granulation tissue (Fig. 7.13).
- Presence of dense bone Diagnosis is confirmed by probing the socket
- Loss of blood clot from the socket due where bare bone is encountered and is
to vigorous rinsing and sucking the extremely sensitive.
mouth. A foul odour is present and the pain is
- Smoking intense, caused due to chemical and thermal
- Oral contraceptives enhance the irrigation of the exposed nerve endings in
fibrinolytic activity. the periodontal and the alveolar bones.
Exodontia 105
Symptoms start from 3rd - 5th day and if of head and neck (E.g.; Ludwigs angina),
untreated will last for 1-2 weeks. therefore immediate treatment is required.
Management: Administration of antibiotics
Management and drainage of pus is advised.
Best method of prevention is by decreasing the g. Septic periosteitis: Inflammation of the
traumatization during extraction and following periosteum of the extracted socket is known
the proper principles of exodontia. as septic periosteitis.
In the first appointment the socket is irrigated Management: Hot moist fermentation and
properly with warm normal saline or mild warm warm saline mouthrinses administered.
antiseptic solution or dilute hydrogen peroxide. Analgesics prescribed to relieve pain.
The socket is then packed with an obtundant
dressing like iodoform gauze dipped in zinc oxide FURTHER READING
eugenol paste or white head varnish. Patient is
recalled after 24 hrs and checked for pain and 1. Archer WH Oral and maxillofacial surgery, 5th
other features. If the features persist then the ed, Vol. 1.
same procedure is repeated for 2-3 times until 2. Basrani Fractures of the teeth.
3. Daniel M Laskin Oral and maxillofacial surgery.
the features disappear. Analgesics are prescribed
to reduce pain. Antibiotics are not required until practice, Vol. 2.
infection is there. 4. Eisele Complications in head and neck surgery.
Curettage, packing or suturing should not 5. GR Seward, M Harris, DA Gown Killey and
be done as this dislodges the granulation tissue Kays outline of oral surgery, Part I, 10th ed.
and delays wound healing. 6. Gustav O Krufer Textbook of oral and
f. Post-operative infections: Most commonly maxillofacial surgery, 6th ed.
7. Howe GL The extraction of teeth, 2nd ed.
occurring post operative infections are
1980.
Herpes and infective endocarditis. 8. Killey HC, Seward GR, Kay LW An outline of
Post operative infections are caused by oral surgery, Part I, Ist ed, 1983.
anaerobic or facultative anaerobic bacterial 9. Peterson, Ellis, Hupp, Tucker Contemporary
that are commensal in the mouth. These oral and maxillofacial surgery, 4th ed. 2006.
infections can spread to various facial spaces 10. Robinson Tooth extraction, a practical guide.
Impaction 8
Impaction is the cessation of eruption of a tooth iii. Ankylosis of the primary or permanent
caused by a physical barrier or ectopic positioning teeth.
of a tooth. An impacted tooth is one that is iv. Over-retained deciduous teeth.
erupted, partially erupted or unerupted and will v. Non-absorbing alveolar bone (dense
not eventually assume a normal arch relationship bone).
with other teeth and tissues. vi. Ectopic position of a tooth bud.
vii. Dilacerations of root.
FREQUENCY OF IMPACTION viii. Associated soft tissue or bony lesions.
(INCIDENCE) ix. Habits involving tongue, finger etc.
2. Systemic:
Mandibular 3rd molar. i. Prenatal causes - hereditary
Maxillary 3rd molar. ii. Post natal causes
Maxillary canine Rickets
Mandibular premolar. Anemia
Maxillary premolar. Tuberculosis
Mandible canine. Congenital syphilis
Maxillary central incisor Malnutrition
Maxillary later incisor Endocrinal disorders can also cause impac-
tion. E.g. in hypothyrodism, achondroplasia,
CAUSES OF IMPACTION there is primary retention of the teeth as there
is lack of osteoclastic activity (due to non
The various etiology of impaction is: resorption of bone overlying the developing
1. Local: tooth).
i. Obstruction in eruption path
Caused due to irregularly positioned teeth COMPLICATIONS OF
and presence of an adjacent teeth, or due IMPACTED TEETH
to high density of overlying and The reasons for the removal of the impacted
surrounding bone. teeth area:
ii. Lack of space in dental arch 1. Infection: Pericoronitis, alveolar abscess,
Occurs due to crowding or super- periosteitis, osteomyelitis and necrosis of the
numerary teeth. jaw takes place.
Impaction 107
2. Pain CONTRAINDICATIONS FOR

3. Fracture of jaw: Occurs due to weakening REMOVAL OF IMPACTED TEETH
of the jaw.
Contraindications for the removal of impacted
4. Trismus:
teeth, primarily involves the patient's physical
It occurs as a sequelae to infection, which
status.
causes difficulty in opening the jaw.
They are:
5. Chronic check biting;
i. Extremes of ages: Very early removal of 3rd
White patch or chronic ulcer is seen in the molar should be deferred until an accurate
area where the tooth hurts, specially in buccal diagnosis of impaction can be made.
mucosa. In an old patient with an impacted tooth
6. Malalignment of other teeth: that shows no sign of disease and that has
Mesial migration of other tooth, e.g. 2nd a thick layer of overlying bone, is best left
molar is caused by the pressure from mesially in-situ.
impacted third molar. ii. Compromised medical status: If a patient's
7. Others: cardiovascular or respiratory or host
Dimness of vision, temperomandibular joint defenses for combating infections are
arthralgia can also occur due to impacted compromised, then the surgeon must
teeth complications. consider leaving the tooth in the alveolar
process.
INDICATIONS FOR REMOVAL OF iii. Probable excessive damage to adjacent
IMPACTED TEETH structures: If the impacted tooth lies in an
area in which its removal may seriously
i. Recurrent pericoronitis/pain/infection. jeopardize adjacent nerves, teeth, pre-
ii. Deep periodontal pocket, associated with viously constructed bridges, it may be
partially erupted tooth. predent to leave the tooth in place.
iii. To prevent dental caries. iv. Availability of adequate space: An erupting
iv. Preservation of root resorption. tooth may simulate an impacted tooth, then
v. Trauma like recurrent check bite may be clinician may choose to defer removal of
responsible for the development of pre- the tooth until eruption is complete.
malignant and malignant lesions of oral v. Socio-economic status: Due to fear or
mucosa. patients with busy schedule, may wish to
vi. To prevent pain of unexplained origin defer the extraction in order to minimize
vii. Prior to orthodontic treatment. the inconvenience.
viii. Management of cysts or tumors of
odontogenic origin. PRE-OPERATIVE ASSESSMENT
ix. Preparation of orthognathic surgery
x. Pre-prosthetic reasons. 1. Clinical Assessment
xi. Impacted teeth in the line of fracture. Clinically, treatment planning is based on
xii. Prophylactic removal, as a part of thorough clinical evaluation of the patient with
preventive dentistry. respect to general and local factors relevant to
xiii. Previous attempted extractions. possible postoperative sequelae.
In general, retruded mandible, restricted Extraoral Techniques
mouth opening and small oral commissures are
The extraoral techniques for detection of
responsible for poor access to the surgical field.
impacted teeth in the mandible are:
Conversely, protruded mandible and large
mouth opening will greatly increase access. The Orthopentamograph (OPG)
clinical assessment for impacted teeth is similar Lateral oblique view of the mandible.
to the pre-operative clinical assessment as For maxillary impactions, the techniques are:
discussed under 'Exodontia'. Orthopentamograph (OPG)
Posterio-anterior view or water's view
2. Radiological Assessment ii. Assessment of Access to the tooth: The
i. Technique: The most common techniques access of the impacted tooth depends on
for radiological assessment of impacted the position of the external oblique ridge
teeth are: (which appears as a radio-opaque line in
Intraoral techniques: the radiograph). If the line is vertical, the
Intraoral periapical radiograph access to the tooth is poor and if it is
Occlusal radiograph horizontal access is good.
Clark's rule: iii. Condition of crown and root of tooth
Clark's rule or tube shift technique is used involved.
to localization of impacted tooth. In this It is similar to as that discussed under
procedure, two exposures are taken, one 'Exodontia'.
in usual position and another in which tube iv. Condition of adjacent structure: It is similar
is shifted by 2 cm to one direction (E.g.; to that described under 'Exodontia'.
in right direction). If in the second film the v. Wharfe's assessment: Scoring details for
impacted tooth has shifted to the same Wharfe assessment are as follows:
direction. (i.e. in right) then the impacted
Category Score
tooth is in the lingual/palatal position,
whereas if it is shifted to the opposite 1. Winters classification Horizontal 2
direction (i.e. in left) then the tooth is in Distoangular 2
the buccal position. This is SLOB rule (Same Mesioangular 1
Vertical 0
Lingual Opposite Buccal) (Figs 8.1A
and B). Contd...
( ) ( )
Figs 8.1A and B: Palatally positioned impacted canine
(Tooth moved in the same direction as that of collimator)
Impaction 109
Contd... c. Red line: It is a perpendicular line dropped
from amber line to an imaginary point
Category Score
of application of an elevator. It is used
2. Height of the mandible 1 - 30 mm 0 to measure the depth at which the
31 - 34 mm 1 impacted teeth lies within the mandible.
35 - 39 mm 2 If the length of the red line is 5 mm or
3. Angulation of 3rd molar 1 - 50 0 less, then the tooth can be conveniently
60 - 69 1
removed. Increase in the length of the
70 - 79 2
80 - 89 3 red line, of every additional millimeter,
90 + 4 renders the removal of impacted tooth
4. Root shape Complex 1 3 times more difficult. If the red line is
Favourable curvature 2 more than 9 mm, then the tooth is best
Unfavourable 3
removed under general anesthesia.
curvature
5. Follicles Normal 0
Possibly enlarged 1
Enlarged 2
6. Path of Exit Space available 0
Distal cusp covered 1
Mesial cusp covered 2
Both covered 3
Total = 33
vi. Winter lines: In an intraoral periapical

radiograph, 3 imaginary lines are drawn Fig. 8.2: W-white line, A-amber line, R-red line.
known as winter lines (Fig. 8.2). They are
as follows: vii. Relation to the inferior alveolar canal:
a. White line: It represents the occlusal plane Relationship of the root apex to the
joining the white enamel cusps of the inferior alveolar canal is important to detect
erupted 1st and 2nd molar and is before extraction, by the help of radiograph
extended posteriorly over the 3rd molar (Fig. 8.3).
region. The relationship of the root apex to the
In a vertically impacted tooth, the inferior alveolar canal can be as follows:
occlusal surface is parallel to the white line, 1. Root apex related but not involving the canal:
whereas in mesioangular impaction the a. Root and canal are separated
occlusal surface of the 3rd molar meets b. Both are adjacent
the white line distal to it. In distoangular c. Superimposed
impaction the occlusal surface meets the 2. Canal related to changes in the roots;
white line in front of it. a. Darkening of the root
b. Amber line: It represents the bone level. b. Dark and bifid root
A level is drawn from the crest of the c. Narrowing of the root
interdental septum between the molars d. Deflected root.
and posteriorly distal to the 3rd molar or 3. Root apex related with changes in the canal:
to the ascending ramus. The amber line a. Interruption
represents the summit of alveolar bone b. Converging canal
covering the impacted tooth. c. Diverted canal
2. Vertical: Long axis of the impacted tooth is

vertical
Fig. 8.5
3. Horizontal: Long axis of the impacted tooth
is horizontal
Fig. 8.3: Relationship of mandibular teeth to
inferior alveolar nerve and mandibular canal
(For color version see plate 1)
STUDY OF COMMONLY
IMPACTED TEETH
Classification Fig. 8.6

4. Distoanglar: Long axis of the impacted tooth
A. Classification of Impacted is distally tilted
Mandibular 3rd Molar
i. Winter's classification: This classification is
based on the long axis of the impacted tooth
(3rd molar) in relation to the long axis of
2nd molar.
1. Mesioangular: Long axis of the impacted
tooth is mesially tilted
Fig. 8.7
5. Buccoangular: Impacted tooth is erupted
buccally
Fig. 8.4 Fig. 8.8
Impaction 111
6. Linguoangular: Impacted tooth is erupted

lingually
Fig. 8.9 Fig. 8.12

7. Inverted: Impacted tooth is erupted inverted
Class III - 3rd molar is totally embedded in
bone from ascending ramus because of absolute
lack of space.
Fig. 8.10
ii. Pell and Gregory classification: There are
three folds to this classification:-
1. Based on the space between 2nd molar and
ramus:
Class I - Space between anterior border of
ramus and distal side of 2nd molar is enough Fig. 8.13
to accommodate the mesiodistal diameter of the 2. Based on relative depth of 3rd molar:
3rd molar. Position A - highest point of 2nd molar and
highest point of impacted 3rd molar is in line.
Fig. 8.11 Fig. 8.14

Class II - Space between distal aspect of 2nd Position B - Highest point of 3rd molar is
molar and anterior border of ramus is less than lower than the highest point of 2nd molar and
the mesiodistal diameter of 3rd molar and hence lies between the occlusal plane of the 2nd molar
partial buried in ramus. and above the cervical line of 2nd molar.
3. Mesioangular impaction: Long axis of the

impacted is mesially tilted
Fig. 8.15
Position C - highest point of 3rd molar lies
below the cervical line of 2nd molar.
Fig. 8.19
4. Transverse, inverted and horizontal impac-
tions are rare.
II. Based on the depth: (Pell and Gregory)
Position A - highest point of 2nd molar and
highest point of impacted 3rd molar is in line.
Fig. 8.16
3. Based on long axis of 3rd molar in relation
to long axis of 2nd molar:
This classification is similar to that of Winter's
classification discussed earlier.
Fig. 8.20
B. Classification of Impacted Maxillary
3rd Molar Position B - highest point of 3rd molar is in
between plane of occlusion and cervical line.
I. Based on the position:
1. Vertical impaction: Long axis, the impacted
tooth is vertical
Fig. 8.21
Position C - highest point of 3rd molar is
below cervical line.
Fig. 8.17
2. Distoangular impaction: Long axis of the
impacted tooth is distally tilted
Fig. 8.22
III. Based on the relation to maxillary sinus floor:
1. Sinus approximation (SA): No bone or a
thin bone is present between impacted 3rd
Fig. 8.18 molar and floor of sinus.
Impaction 113
2. No sinus approximation (NSA): 2 mm or wound healing. Tooth sectioning is done for easy
more bone is present between the sinus floor removal and with fewer problems. If excess
and impacted 3rd molar. sectioning is done it takes more time. Thus,
proper bone removal and tooth sectioning is
C. Classification of Impacted needed to minimize surgery time and hasten
Maxillary Canine healing.
'Kelsey Fry' is a technique used to remove
I. Based on the location:-
impacted mandibular third molar.
1. Labially or palatally placed.
2. Intermediate position
Steps of Surgical Removal
i. Crown between lateral incisor and
premolar. Step 1: Reflection of adequate flap for
ii. Crown above root tip with labial or accessibility (Fig. 8.23A).
palatal orientation of lateral incisor or Step 2: Removal of overlying bone (Fig. 8.23B).
premolar. Step 3: Sectioning of the tooth (Fig. 8.23C)
3. Aberrant position: Impacted maxillary Step 4: Delivery of the sectioned tooth with
canine lie in maxillary sinus or nasal cavity. elevator (Fig. 8.23D).
Step 5: Wound debridement and closure
II. Based on the position and location:-
(suturing).
Class I - Palatally placed canine:-
1. Horizontal position
2. Vertical position
3. Semivertical position
Class II - Labially or Buccally placed canine:-
1. Horizontal position
2. Vertical position
3. Semi vertical position
Class III - Involving both buccal and palatal
bone:-
1. Crown of impacted canine on the palatal
aspect and root on the buccal aspect. Fig. 8.23A: Step 1- Flap reflection
2. Root of impacted canine on the palatal
aspect and crown on the buccal aspect.
Class IV - Canine impacted in the alveolar
process between the incisor and premolar.
Class V - Canine impacted in edentulous maxilla.
REMOVAL OF THE IMPACTED TEETH

In surgical removal of impacted tooth, adequate
amount of bone should be removed to make
the process easy and less time consuming. Excess
bone removal leads to difficulty and prolong Fig. 8.23B: Step 2- Bone removal
Reflection of flap in impacted Mandibular 3rd

molar: Envelop flap is reflected from mesial
papilla of mandibular first molar, moving around
the neck of the tooth till the distal papilla of
second molar and then running posteriorly and
laterally till the anterior border of the mandible
to approximate the external oblique ridge (Fig.
8.24). The incision should never continue
posteriorly in straight line as it may damage the
sublingual space and the lingual nerve. Releasing
Fig. 8.23C: Step 3- Sectioning of tooth incisions may be needed for deeply embedded
tooth (Fig. 8.25).
Fig. 8.24: Incision extended posteriorly and

laterally
Fig. 8.23D: Step 4- Delivery of tooth

Fig. 8.25: Releasing incision
Step 1: Reflection of adequate flap for
accessibility: Overlying tissue must be removed Reflection of flap in impacted maxillary 3rd
for accessibility and visibility and muco- molar: Envelop flap is reflected from mesial
periosteum flap must be reflected for easy aspect of first molar posteriorly till distobuccal
placement and stabilization of instruments. aspect of second molar (Fig. 8.26). Releasing
incision may be made from mesial aspect of
Types of Flaps and Incision second molar for deeply embedded tooth
(Fig. 8.27).
1. Envelop flap: This is most preferred as it is
easy to close postoperatively and better Reflection of flap in impacted maxillary canine:
healing is there. For buccally placed canine trapezoidal or semi
2. Releasing incision on envelop flap: This is lunar flaps are reflected with anterior releasing
done for greater accessibility and visibility. incision.
3. Three-cornered flap: This is less preferred as
poor healing is there but it provides better
accessibility.
All the flaps are reflected in such a manner
that they are closed over solid bone. Thus, Fig. 8.26: Incision for maxillary 3rd molar
incision is extended to one tooth on either side. impaction
Impaction 115
Fig. 8.27: Releasing incision
For palatally placed canine flap is reflected Fig. 8.29: Occlusal bone removed
on the gingival side from mesial side of first molar to expose tooth
till canine on the other side (for unilateral cases)
(Fig. 8.28) and till mesial side of first molar on
other side (for bilateral cases).
Fig. 8.30: Buccal bone removed

Step 3: Sectioning of the tooth: Sectioning of
tooth depends on the angulations of tooth and
also divergent roots and the depth of impaction.
Sectioning is first done by bur and then broken
with the help of straight elevator, so as to prevent
Fig. 8.28: Flap reflection in unilateral damage to the lingual nerve.
impacted maxillary canine
Sectioning of impacted Mandibular 3rd molar:
Step 2: Removal of overlying bone: Removal The sectioning of various impacted Mandibular
of the bone covering the impacted tooth should 3rd molar tooth is explained below and its
be done in the following sequence: removal is done according to the numbering.
i. First of all, the occlusal aspect removal
should be done to expose the tooth (Fig. Mesioangular impaction: The distal aspect of the
8.29). crown is sectioned from the tooth. First the distal
ii. Then the Buccal aspect of the bone should portion (1) is removed, followed by the mesial
be removed till the cervical margin of the portion (2) of the tooth. It is the easiest to remove
tooth (Fig. 8.30). (Fig. 8.31).
iii. Then, bone between the tooth and the Horizontal impaction: The distal portion of the
cortical bone should be removed to provide crown is sectioned first (1) then the distal part
better access. This process is known as (2) of the root followed by the mesial (3) portion
'Ditching'. of the tooth (Fig. 8.32).
Purchase points are made on the tooth for
better elevation of tooth.
Precaution must be taken not to remove any
bone from the lingual side, to prevent lingual
nerve damage in case of lower 3rd molars
impaction. The depth of bone removal depends
on the depth of impaction, morphology of roots
and angulations of tooth. Fig. 8.31
enough to lift the tooth, as impacted tooth are

weak. The periodontal ligament of impacted
tooth are weak, as they do not receive occlusal
forces, hence it is easily removed.
Most commonly used elevators for delivering
the impacted tooth are:
Fig. 8.32 Straight elevator
Vertical impaction: The tooth is sectioned into Paired Cryer elevator
mesial and distal half; first the distal half (1) is Crane pick elevator
removed then the mesial half (2) (Fig. 8.33). The curved elevators, used for gaining access
are:
Pott's elevator
Miller's elevator
Step 5: Debridement of wound and wound
closure: Debridement of the wound is done by:
Removing the bone chip and debris from
Fig. 8.33 the wound.
Distoangular impaction: The crown of the tooth Periapical curettage
(1) is removed first, then either tooth roots {(2) Using bone file to smoother the sharp bony
+ (3)} are removed together or first distal (2) edges.
removed followed by mesial (3) (Fig. 8.34). Irrigating with sterile saline.
Control of bleeding.
Wound closure should be done by placing
3-4 sutures for envelop flap and if releasing
incision is made then 1 more additional suture
is placed. Moist pressure packs should be given.
Postoperative Instructions
Fig. 8.34
It is similar to that discussed under 'Exodontia'.
Sectioning of impacted maxillary 3rd molar: In
case of impacted maxillary 3rd molar sectioning Complications
is generally not needed as bone is thin and elastic.
It is similar to that discussed under 'Exodontia'.
In order patients, where bone is thick and
inelastic, then generally bone is removed and
FURTHER READING
thus rarely needs sectioning. If sectioning is done
then only bur is used, as use of chisel may be 1. Archer WH Oral and maxillofacial surgery 5th
ed. Vol. 1.
injurious and can damage the sinus. Sectioning
2. Eisele Complications in head and neck surgery.
should be done along the cervical line. 3. Gustav O Kruger Textbook of oral and
Sectioning in impacted canine: Sectioning of maxillofacial surgery, 6th ed.
impacted maxillary or Mandibular canine is done 4. Howe GL Minor oral surgery, 3rd ed, 1996.
along the cervical margin. 5. Killey HC, Seward GR, Kay LW An outline of
oral surgery, Part I, 1st ed, 1983.
Step 4: Delivery of the sectioned tooth with 6. Peterson, Ellis, Hupp, Tucker Contemporary
elevator: The sectioned tooth is removed from oral and maxillofacial surgery, 4th ed, 2006.
the bone with the help of elevator. Excess force 7. Waite DE Textbook of practical oral and
should not be applied by the elevator but just maxillofacial surgery, 3rd ed, 1987.
UNIT IV
MINOR ORAL
SURGERY
Infection of the
Orofacial Region
9
INTRODUCTION Odontogenic infections are infectious

arising from ameloblasts, pulpal tissues,
Infection is the invasion of the body by harmful
periodontal tissues, periapical tissues, pericoronal
organism (pathogens), such as bacteria, fungi,
tissues.
protozoa, rickettsiae, or viruses. The infective
Non-odontogenic infections are infectious
agent may be transmitted by a patient or carrier
that invade through the mucosa, skin due to
in airborne droplets expelled during coughing
certain iatrogenic or other injurious lesions.
and sneezing or by direct contact, such as kissing
or sexual intercourse; by animal or insect -
MICROBIOLOGY OF
vector; by ingestion of contaminated food or
ODONTOGENIC INFECTION
drink; or from an infected mother to the fetus
during pregnancy or birth. Pathogenic organism Micro-organism Percent of incidence present in
present in soil, organism from animal pulpal and periapical infection
intermediate hosts, or those living as commensal Streptococci
on the body can also cause infection. Organism ( and non-hemolytic) 50
may invade via a wound or bite or through Veillonella sp. 29
mucous membranes. Propioni bacillus sp. 20
After an incubation period symptoms appear, Peptostreptococcus sp. 18
usually consisting of either localized inflammation Staphylococci 16
Bacteriods sp. 15
and pain or more remote effects.
Streptococcus foecolis 13
Treatment with antibiotics is usually effective Candida albicans 7
against most infections, but there are few specific Neisseria sp. 5
treatment for many of the common viral Lactobacillus sp. 5
infections. Fusobacteria 5
Infections of the head and neck region can Proteus sp. 4
be odontogenic (originating from dental and Escherichia coli 4
Diptheroids 4
associated structures) and non-odontogenic
Actinomyces sp. 4
(originating from other structures).
DISTRIBUTION OF INDIGENOUS SPREAD OF INFECTION (FACTORS

MICROORGANISM IN HEAD AND CONTROLLING SPREAD OF
NECK REGION INFECTION)
Organism Mouth Oropharynx I. General Factors
Gram + Faculative cocci
- Streptococcus ++++ ++++ 1. Micro organism - quantity and virulence
- Streptococcus + ++ 2. Anatomic considerations - Infection tends to
Nonhemolytic streptococcus +++ +++ spread through path of least resistance.
Pneumococci + ++
Staphylococcus Epidermidis +++ +
Barriers are - alveolar bone, periosteum,
Staphylococcus Areus +++ +++ muscles and fascia.
Gram + Anaerobic Streptococcus +++ +++ 3. Personal resistance to infection - In patients
(peptostreptococcus)
with AIDS, diabetes, leukaemia etc have
Gram + Faculative Rod
Diptheroids ++++ +++ low resistance, increase susceptibility to
Lactobacillus +++ 0 infections.
Actinomyces +++ +++
Gram + Anaerobic Rod
Clostridium + 0 II. Host Defense/Resistance
Diptheroids +++ +++
Gram -ve Faculative coccus 1. Local Factor
Neisseria +++ +++ i. Epithelial lining of the skin and mucous
Gram -ve Anaerobic cocci
membrane
Veillonellae ++++ +++
Gram -ve Anaerobic Rods ii. Secretion and drainage from the body
Pseudomonus + 0 tissues
Coliform Bacteria + + iii. Normal commensals present in the body
Gram -ve Anaerobic Rods
Fusobacterium +++ + 2. Humoral Immunity (Immunoglobulin
Bacteriods +++ + produced by the B- lymphocytes)
Spirochaetes +++ + 3. Cellular Immunity (phagocytic action of the
Measles +++ +++
T- lymphocytes)
+ + + + = Major component
+ + + = Minor component
+ + = May be present or minor component
+ = very minor component
0 = absent
SPREAD OF INFECTIONS (ANATOMIC CONSIDERATIONS)
Sl. Involved tooth Usual exit Relation of muscle Site of Muscle playing the role
No. from bone to root apices localisation in spread
1. Upper central labial above Oral vestibule Orbicularis oris +
incisor dense C.T at base of nose
2. Upper lateral incisor Labial above Oral vestibule Root apex curved palatally
Palatal Palatal
3. Upper canine labial Above or below Oral vestibule Levator Anguli
Canine space Oris
Contd...
Infection of the Orofacial Region 121
Contd...
Sl. Involved tooth Usual exit Relation of muscle Site of Muscle playing the role
No. from bone to root apices localisation in spread
4. Upper premolar Buccal above Oral vestibule Buccinator muscle

Palatal Palate
5. Upper molars Buccal Above or below Oral vestibule Buccinator muscle
Palatal Buccal space
Palate (or maxillary sinus)
6. Lower incisors labial Above below Oral vestibule Mentalis muscle
Submental space
7. Lower canine labial Below Oral vestibule
8. Lower premolars buccal Below Oral vestibule
9. Lower 1st molar Buccal Below Oral vestibule Buccinator muscle
lingual Above Buccal space Buccinator muscle
Below Sublingual space Mylohyoid muscle
10. Lower 2nd molars Buccal Below Oral vestibule Buccinator muscle
Lingual Above Buccal space Buccinator muscle
Below Sublingual space Mylohyoid muscle
Above Submandibular Mylohyoid muscle
space
11. Lower 3rd molar lingual Above Submandibular or Mylohyoid muscle
Pterygomandibular
space
* "Spread of infection is always along the path of least resistance"
SPREAD OF INFECTION FROM

MANDIBULAR 3RD MOLAR
In mandibular 3rd molar, the roots are near
lingual plate, Therefore buccal palate perforation
is not seen.
Generally, infection spreads to sub-
mandibular space and if it spreads beyond the
posterior extend of the mylohyoid muscle (seen
in cases of musio-angular or horizontal impac-
tion), infection goes to pterygomandibular space
leading to paraesthesia and swelling of the area.
If infection spreads medial to medial
pterygoid muscle then it reaches the
Fig. 9.1: Pathway of the spread of infections parapharygeal spaces (Fig. 9.2).
2. Severe Infection
Trival + signs of toxicity
Paleness
Rapid respiration
Rapid thrombing pulse
Shivering
Fever
Lethargy
Diaphoresis (severe sweating)
Fig. 9.2: Spread of infection from infected 3. Extreme Infection
mandibular third molar
Trivial + sign of toxicity + CNS changes
Impaired eye movement/vision
PATHWAY OF DENTAL INFECTION Decreased level of consciousness
Meningeal irritation (severe headache, stiff
neck, vomiting)
Edema of eyelids
Airway compromise
Difficulty in swallowing
Diagnosis
Lab Studies
Uncomplicated abscess: No laboratory studies
are required.
Complicated abscess:
The CBC count may reveal leukocytosis
ODONTOGENIC INFECTION
with neutrophil predominance.
(GENERAL STUDY) Obtain a blood culture (aerobic and
Clinical Features (Signs and anaerobic) before initiating parental
Symptoms) antibiotic.
Needle aspiration is indicated for gram
1. Mild Infection stain and culture.
Trivial Inflammatory sign
Imaging Studies
Dolor
Calor Uncomplicated abscess: No imaging studies
Rubor are required.
Tumor Complicated abscess:
Loss of function Plain radiography represents the first level
Lymphadenopathy of investigation because it is readily
Pyrexia (fever) available.
Lateral and anteroposterior neck views secure the airway via endotracheal intubation
may reveal a soft tissue neck mass that or tracheostomy.
reveals abscess. Properly collect specimen for gram stain and
Panoramic radiograph (pantomography) culture.
is helpful to indicate whether bone or Administer empiric antibiotic therapy.
teeth is involved. Administer analgesia.
C.T scan with intravenous contrast is the Hydrate the patient and use of treatment
most accurate method to determine the agent. ( Hot packs are contraindicated in case
local relationship of the inflammatory of cellulitis as can lead to abscess)
process to the surrounding vital
structures. Surgical Care
The primary therapeutic modality is surgical
PROCEDURES
drainage of any pus collection. Incision and
Aspiration rupture of the abscess quickly accelerates
resolution of the infection. Abscess should
Confirm presence of the abscess via needle be drained even if patient is toxic, since
aspiration. toxemia usually results from the absorption
If pus is obtained, do not aspirate more than of degenerated tissue products and bacterial
1 or 2 drops. Leave the abscess as later, area toxins.
is easier to find for further management. Emergent surgery is indicated in the
If pus cannot be aspirated, manage medically operating room if the airway is threatened
until a more localized infection develops. or if the pulse is deteriorating.
Incision and drainage may be performed only
if pus can be aspirated. Consultations
Packing a periapical abscess is generally not
necessary. Consult a dentist if the patient has an
uncomplicated abscess.
Differential Diagnosis Consult a maxillofacial oral surgeon if the
Three stages in progression of acute odontogenic patient has a complicated abscess.
infection:
1. Periapical Osteitis or Apical periodontitis - Diet
infection confined within alveolar bone Diet is as tolerated. However, a soft bland diet
2. Cellulitis - Infection spreads through bone, is usually preferred.
periosteum into soft tissue
- No suppuration. Activity
3. Stage of Abscess formation - Suppuration and
localization within 72 hours of cellulitis. Activity is as tolerated.
Treatment TREATMENT OF ODONTOGENIC

INFECTION
Medical Care Treatment of odontogenic infection depends on:
Assess the airway upon respiratory distress, a. Stage of infection
oropharyngeal tissue swelling or inability to b. Physiologic response of the patient.
Sl. No. Stage of infection Response to infection Suggested treatment

1. Periapical Osteitis
a. Infection confined within the bone Non- toxic Prophylactic antibiotic
and extraction of tooth
b. Tooth extruded from socket Toxic (elevated temperature Open pulp chamber and give
> 38 C, Chills, swelling. supportive care.
c. Tooth painful to biting or percussions Malaise, anorexia, W.B.C etc) (antibiotic, analgesic, hot
application until patient is
no longer toxic)
2. Cellulitis
a. Swelling not sharply demarcated Non-toxic Prophylactic antibiotic and
extraction of the involved tooth.
b. Tissue have doughly consistency Toxic Open pulp chamber and give
supportive care until patient is
non-toxic.
c. No fluctuation
3. Abscess
a. Swelling distinctly outlined Non-toxic Evaluation of pus by incision
drainage and/or extraction of
involved tooth.
b. Tooth have firm, consistency Toxic Prophylactic antibiotic and
drainage by incision and
drainage and/or extraction
c. Fluctuation elicited.
Note: If tooth to be conserve by RCT, pulp chamber should be opened.
PRINCIPLES FOR THE USE OF PRINCIPLES FOR THE USE OF

PROPHYLACTIC ANTIBIOTICS THERAPEUTIC ANTIBIOTICS
1. The operative procedure must have a risk
1. Identification of the causative organism.
of significant bacterial contamination and a
high incidence of infection. 2. Determination of the antibiotic sensitivity
2. The organism most likely to cause the 3. Use of specific, narrow- spectrum antibiotics
infection must be known. 4. Use of least toxic antibiotic.
3. The antibiotic susceptibility of the causative 5. Patient drug history.
organism must be known. 6. Use of bacteriocidal rather than bacteriostatic
4. To be effective and to minimize adverse drugs.
effects, the antibiotic must be in the tissue 7. Use of antibiotics with a proven history of
at the time of contamination (operation), and
success.
it must be continued for no more than four
hours after cessation of contamination. 8. Cost of antibiotics.
5. The drug must be given in dosages sufficient
to reach four times the MIC of the causative Common Antibiotic Regime Used
organism (MIC = Minimum inhibitory
concentration of an antibiotic for a specific Amoxycillin 3 gm, 1 hr prior to procedure
bacteria). + Amoxycillin 1.5 gm, 6 hr after initial dose.
For children, INFECTION OF THE PULPAL

Amoxycillin 15 mg/kg, 1 hr before procedure AND PERIAPICAL TISSUES
+ Amoxycillin half initial dose, 6 hr after initial
Etiology
dose.
In pencillin sensitive patients, 1. Physical
Erythromycin or clindamycin. A. mechanical
In case of parenteral usage, i. accidental
Ampicillin, clindamycin, gentamycin or ii. iatrogenic
vancomycin. iii. pathological
iv. aerodontalgia
B. Thermal
PRINCIPLES OF INCISION i. heat
AND DRAINAGE ii. friction
iii. cold
1. Knowledge of local anatomy of the area to
2. Chemical
be incised.
3. Bacterial
2. Incision should be made in the most
i. caries
dependent area. (Incision should not be
ii. plaque
made in centre as causes necrosis and iii. anachoretic pulpitis
scarring)
3. Wide incisions for drainage (has technical and STUDY OF SOME PULPAL AND
esthetic problems). PERIAPICAL INFECTIONS
4. Incision placed in esthetically accepted area.
Focal Reversible Pulpitis
Parallel to the skin folds or shadow of
or Pulpal Hyperemia
mandible.
It is an early, mild, transient pulpitis localized
Hilton's method of abscess drainage chiefly to the pulpal ends of the irritated dental
Closed blades of sinus forceps are thrust through tubules.
the incision and into the abscess, ensures that
no blood vessel or nerve is damaged. Features
Tooth is sensitive to thermal changes specially
Causes For The Failure cold.
in Treatment of Infection Hyperactive to electrical changes.
Clinically visible deep caries or large metallic
Inadequate surgical treatment restoration.
Depressed host defenses Pain can be elicited which subsides after a
Presence of foreign body. transient period.
Antibiotic problems:
Drug not reaching infection Chronic Hyperplastic
Dose not adequate Pulpitis or Pulp Polyp
Wrong bacterial diagnosis It is an excessive exuberant proliferation of
Wrong antibiotic chronically inflamed dental pulpal tissues.
Features Features
Exclusively seen in children and young Generally asymptomatic but may show mild
adults. pain or sensitivity on percussion.
Clinically visible large open carious lesion, Extraoral and/or intraoral swelling with or
pinkish red globular tissue seen protruding without expansion of cortical plates may be
from pulp chamber. there.
Generally insensitive to touch but may bleed May lead to abscess, cellulites or even fistula.
on manipulation. Chronic Apical Periodontitis or
Should be carefully differentiated from Periapical Granuloma
gingival proliferation.
It is a localized mass of chronic granulation tissues
associated with the root of an infected tooth or
Acute Pulpitis
teeth.
It is an extensive reversible or irreversible acute
infection of the dental pulp. Features
Sensitivity with mild or severe pain is felt
Features which can be localized on percussion or while
chewing.
Reversible Irreversible Extrusion of tooth from socket may be there.
pulpitis pulpitis Inflammation, edema and swelling can be
History Slight sensitivity Constant or seen intra and extraorally.
or occasional pain intermittent pain
Periapical and
Pain Momentary and Continuous delayed
immediate, sharp onset, throbbing persists Periodontal Abscess
in nature, for minutes to hours
Features
dissipates after after removal
removal of stimulus of stimulus Features Periapical abscess Periodontal abscess
Location Localized Not localized
Cause Pulpal infection Periodontal infection
Change of No difference Pain increases
Pain Severe and throbbing Severe and throbbing
posture
Swelling In mucobuccal region, In attached gingiva.
Thermal test Responds Delayed response
usually near apex of
immediately
involved tooth
Electric pulp Early response Early, delayed or Tenderness Present Present
test mixed response. to percussion
Percussion Negative Negative in early stages, Sinus May be present May be present
later positive when discharge
periapex involve. Mobility Seen at later stages Seen even at earlier
Radiograph Negative May show widening stages
of PDL spaces. Pocket Single and narrow Multiple, wide
coronally
Pulp Necrotic and infected Vital
Apical Periodontal Cyst or Periapical Radiographic Localized bone loss Generalised bone loss
Cyst (Radicular Cyst, Bay Cyst) feature which is mostly which is mostly
horizontal and more vertical and more
It is a sequence of periapical granuloma caused near the apex of near the coronal
due to necrosis of pulpal tissues. A true cyst is tooth portion of the tooth
Treatment Root canal therapy Periodontal
a pathological cavity lined by epithelial or non-
or extraction Intervention.
epithelial tissues and is often filled with fluid.
SPACES INVOLVED IN iii. Sublingual space

ODONTOGENIC INFECTIONS iv. Buccal space
1. Primary Spaces 2. Secondary Spaces
A. MAXILLARY a. Masseteric space
i. Canine space b. Pterygomandibular space
ii. Buccal space c. Superficial and deep temporal space
iii. Infratemporal space d. Lateral pharyngeal space
B. MANDIBULAR e. Retropharyngeal space
i. Submental space f. Prevertebral spaces
ii. Submandibular space g. Parotid space
PRIMARY MAXILLARY SPACES
Spaces Canine fossa/ Buccal Space Infratemporal Space

Infraorbital space
i. Location/Boundaries
Superiorly Infraorbital ridge Zygomatic Arch Zygomatic arch and
infratemporal surface of
greater wing of sphenoid.
Inferiorly Canninus muscle Lower border of mandible Lateral pterygoid muscle
Anteriorly Orbicularis oris Orbicularis Oris, Zygomaticus Infratemporal surface of

major, muscle over Ramus maxilla
Posteriorly Buccinator muscle Masseter muscle over ramus Parotid gland

Medially Anterolateral surface of Buccinator muscle and Medial pterygoid plate, lateral
maxilla masseter muscle overlying pterygoid muscle, medial
anterior border of ramus. pterygoid muscle, lower part
of temporal fossa and lateral
wall of pharynx.
Laterally ----------- Skin, subcutaneous tissue and Ramus of mandible and
platysma temporalis muscle.
ii. Contents ---------- Buccal pad of fat, stenson's Medial pterygoid muscle,
duct, facial artery. lateral pterygoid muscle,
pterygoid plexus of vein,
maxillary artery, mandible
nerve, middle meningeal
artery.
iii. Features Infection spreads from Infection spread from Trismus
maxillary cuspid and from maxillary and mandibular
nasal infection. premolars and molars
Swelling of cheek and upper Gum boil or prominent E/O Swelling of area and difficult
lip. swelling from infraorbital to open eye
region till lower border of
Obliteration of nasolabial fold,
mandible
drooping of angle of mouth,
odema of lower eyelid.
Contd...
Contd...
Spaces Canine fossa/ Buccal Space Infratemporal Space
Infraorbital space
iv. Surgical treatment Approached through the Approached through cheek Approached I/O from buccal
(incision and drainage) mucosa of buccal vestibule in mucosa by horizontal incision vestibule opposite to 2nd and
region of lateral incisor and near premolar and molar 3rd molar.
canine. region Approached E/O at the upper
and posterior edge of
temproalis muscle within the
hairline.
Fig. 9.3: Spreed infections to buccal space Fig. 9.4: Cannine space and its boundries
PRIMARY MANDIBULAR SPACES
Spaces Sublingual space Submandibular space Submental space
i. Location/boundaries
Superiorly Mucosa or oral cavity Medial aspect of mandible Mylohyoid muscle.
and the attachment of
mylohyoid muscle.
Inferiorly Mylohyoid muscle Anterior and posterior bellies Suprahyoid portion of deep
of digastric cervical fascia.
Anteriorly Lingual aspect of mandible Anterior belly of digasrtic and ---
mylohyoid muscle.
Posteriorly At the midline, by body of Floor is formed by hyoglossus ---
hyoid bone. muscle.
Medially Geniohyoid, genioglossus and Mylohyoid, hyoglossus and ---
styloglossus muscle styloglossus muscle.
Contd...
Contd...
Spaces Sublingual space Submandibular space Submental space
Laterally Lingual aspect of mandible Skin, superficial fascia, Lower body of mandible of
platysma and superficial layer mandible and belly of
of deep cervical fascia. digastric.
ii. Contents Geniohyoid, genioglossus, Superficial lobe of Submental lymph nodes and
hyoglossus muscle. Also submandibular salivary gland, anterior jugular veins.
contain submandibillar submandibular lymph node,
salivary gland and duct, facial artery and vein.
sublingual salivary gland,
lingual nerve and hyoglossal
nerve.
iii. Features Infection spreads from Infection spreads from Infection spreads from
mandibular anteriors, mandibular molars or mandibular anterior teeth.
premolars and 1st molar. secondary from sublingual Distinct firm extraoral swelling
Extra orally, No swelling space. along the midline beneath the
Intra oral, painful firm Firm, extraoral swelling below chin.
swelling in floor of mouth. inferior border of mandible. Mobility and tenderness on
Pain, discomfort in Tenderness, dysphagia, percussion of teeth.
deglutition, airway obstruction trismus and sensitivity of teeth
and affected speech. to percussion.
iv. Treatment (incision and Bilateral intraoral incision is Bilateral through and through A blunt dissection is carried
drainage) made through the mucosa, incisions made along the out by making a transverse
parallel to wharton's duct at shadow of mandible through incision in skin below the
the base of alveolar process. the skin, superficial fascia symphysis of mandible.
blunt dissection through
platysma
Fig. 9.5: Spread of infection to Fig. 9.6: Spread of infection to

submandibular space sublingual space
Fig. 9.7: Spread of infection of submental space
MASTIGATORY SPACES
Spaces Sub-masseteric space Pterygomandibular space Temporal space

(superfifcial and deep)
i. Location/Boundaries
Superiorly Zygomatic Arch Lateral pterygoid Superficial temporal pouch

muscle. in between temporal fascia
and temporalis muscle.
Inferiorly Masseteric muscle attachment on
the mandible. -----
Anteriorly Anterior border of massetric Pterygomandibular Raphe. Deep temporal pouch lies
muscle and Buccinator and between temporal muscle and
fascia of parotid gland. skull.
Posteriorly Parotid gland and posterior Parotid gland.

aspect of masseter.
Medially Lateral aspect of Ramus of Lateral aspect of medial

mandible. pterygoid muscle.
Laterally Medial border of masseter Medial surface of Ramus.

muscle.
ii. Contents Muscles of mastication Lingual nerve mandibular Communicates directly with
(massetric, lateral and medial nerve, Inferior alveolar nerve infratemporal and
pterygoid and temporalis) pterygopalatine fossa.
Ramus of mandible. Mandibular artery
Buccal nerve, inferior alveolar Mylohyoid nerve and vessels.
nerve. Loose connective tissue.
iii. Features Infection spreads through lower Infection spreads from Pain and trismus. Swelling over
3rd molar mandibular 3rd molar, and the temporal region.
Tenderness and severe pain in also from maxillary 3rd
ramus region. molar after contaminated.
Trismus and swelling extends Inferior alveolar nerve block.
from lower border of mandible to No E/O swelling
zygomatic arch. Tenderness dysphagia.
Oedema in 3rd molar area.
Contd...
Contd...
Spaces Sub-masseteric space Pterygomandibular space Temporal space
(superfifcial and deep)
iv. Surgical treatment Extra oral is mostly used in Extraoral incision is Extra oral incision in temporal
(Incision and drainage) case of trismus in skin behind made in skin below region, which should be above
angle of mandible. angle of mandible. hair line and 45 to zygomatic
arch.
Intraoral vertical incision is Intraoral vertical incision

placed over lower part of is made on anterior and
anterior border of ramus. medial aspect of ramus of
mandible.
*Masticatory space infection usually results from-

Infection of the last two molars
External or internal trauma to the mandibular
angle region
Non aseptic technique in LA
Fig. 9.10: Secondary spaces and its boundaries
Fig. 9.8: Pterygomandibular space

and its boundries
Fig. 9.11: Site for extra oral incisions

Fig. 9.9: Masticatory space and boundaries to drain abscess
LUDWIG'S ANGINA Features

Angina is chocking or suffocating sensation. Always involves all the three - sublingual,
Ludwigs Angina is a firm, acute, toxic cellulitis submandibular and submental spaces
involving bilaterally the sublingual, submandi- bilaterally
bular and submental spaces. Rapidly developing board-like, brawny, firm,
indurated, diffused, non-fluctuating swelling
Etiology in the floor of the mouth which shows no
Infections of mandibular molars pitting on pressure (Fig. 9.13).
Postextraction complication Discomfort and pain while eating, swallowing,
Compound mandibular fractures. breathing, speaking and chewing.
Submandibular gland sialadenitis Characteristic 'OPEN MOUTH' Appearance
Oral soft tissue lacerations. with elevated, protruded tongue and
Microbiology elevated floor of mouth.
Toxic signs of high fever, rapid pulse, chills,
Streptococcal infections or mixed flora
rigor, excessive salivation, trismus and angina.
Reports also show the presence of
Staphylococci, E.Coli, Pseudomonas and As infection continues, edema of tongue
certain anaerobes. increases and there is high risk of death due
to suffocation
Pathogenesis
According to many authors, like Kruger,
Topazian and Ludwig, the infection starts in
submandibular space and later spreads, but by
this it is difficult to explain the pathogenesis.
Hence, Laskin tells that the infection starts at the
sublingual space and spreads bilaterally
extending posteriorly over mylohyoid muscle to
involve the submandibular and submental
spaces at a later stage. Further more, the
infection spreads to the pharyngeal spaces and
the mediastenum (Fig. 9.12).
Fig. 9.13: Clinical view of a patient suffering from

Ludwigs angina (For color version see plate 2)
Treatment
1. General management of infection is
manifested to destroy or inhibit bacterial
growth and to increase the physiological
defense mechanism of patient.
Bed rest is advised, along with hydration.
Fig. 9.12: Spread of infection Empirical antibiotics should be
in Ludwig's angina administered.
Airway potency and vital sign manage- Fever, nausea, vomiting, chills, rigor, stiffness
ment. (may need tracheostomy- and constitutional symptoms.
Laryngotomy and Cricothyroidotomy/ Tender and painful eye, paralysis of the
Tracteotomy are more preferred) extraocular muscles (ophthalmoplegia),
Heat and cold therapy (apply moist heat edema of eyelid, proptosis, and conjunctivitis.
over the area for 20-30 min/hour).
2. Surgical intervention is instituted for releasing Investigations
tissue tension and for pus drainage. Incisions
Mainly diagnosed by the clinical features along
are made separately for submandibular,
with skull radiograph, C.T Scan, M.R.I and CSF
sublingual and submental spaces as explained
examination.
earlier and the pus is collected which is inturn
send for gram stain, culture and antibiotic
Treatment
sensitivity test. An artery forcep or Hilton's
forcep is thrust through the incision and a Immediate empirical antibiotic therapy like
drain is fixed to enable complete clearing of I.V- chloramphenicol, Aminoglycosides,
pus. (Hilton's method of Abscess drainage)- Trimethoprim, Sulphamethazole.
sublingual and submental space can be In case of abscess surgical drainage via
approached through the incision line made craniotomy procedure is done.
for the submandibular space, but this is not Emergency neurosurgical intervention is
preferred, as here excision of submandibular required.
muscle has to be done.
Prognosis
Prognosis
Invariably fatal whereby death occurs due to
If not treated early and efficiently can lead to brain abscess or meningitis.
death due to aspiration causing severe sepsis.
COMPLICATIONS OF 2. Brain Abscess

ODONTOGENIC INFECTION It is the second most common neurological
complication, after meningitis of head and neck
1. Cavernous Sinus Thrombosis
infections, occurring from bacterimia accom-
It is a septic thrombosis of cavernous sinus caused panying odontogenic infections.
due to an infection in the orofacial region, like
sinusitis, abscess or cellulitis of the orbit, upper Features
lip, nose, maxilla or dental tissues. The classical Inflammation, localized edema with septic
dangerous area of the face (Triangular area thrombosis and abscess may develop.
having its base as the upper lip and its apex as Headache, nausea, vomiting, chills, rigor,
the root of nose) has valveless venous drainage fever.
which empty itself into the cavernous sinus thus Sometimes headache is the only symptoms
making it easier for any infection of the region present.
to enter into the sinus. Papilledema
Hemiplegia and hemianopsia
Features Convulsion and abberant nerve palsy.
Suddenly occurring, widely spreading and Stupor, confusion and subtle change in
severe in nature. personality is also seen.
Treatment Predisposing factors of the condition

Antibiotic therapy (I.V - chloramphenicol) Improper oral hygiene
along with steroid ( Dexamethazone and Occlusal trauma
mannitol). Gingival infection
Lumbar puncture if meningitis is suspected. Food lodgment
Reduced body resistance.
Surgical drainage of abscess by craniotomy.
Types of Pericoronitis
3. Meningitis Pericoronitis can be classified into 3 types
It is the most common neurologic complications depending upon the features present:
in orofacial infections whereby bacteria infect the i. Acute: Here all the classical features are
arachnoid mater, pia mater and CSF. present
ii. Subacute: Here the classical symptoms have
Features subsided but certain signs are still present
along with the presence of a sinus tract.
Headache, fever, nausea, vomiting, chill, iii. Chronic: Here most of the features have
rigor. subsided but a distinct fistulous tract is
Pain and stiffness of neck and back. present.
Confusion, stupor, seizure and coma.
Kernig's sign positive (strong resistance is felt Features
when an attempt is made to extend the knee Crypt like area is formed between the tooth
from flexed thigh position) and operculum which favours food and
Brudzinski's sign positive (abrupt neck flexion debris lodgement and thus microbial
in supine patient resulting in involuntary proliferation (Fig. 9.14).
flexion of knee. Severe localized or radiating pain.
Distinct extraoral and/or intraoral swelling
Treatment near the angle of mandible of the affected
Lumbar puncture is done and CSF is side and/or opposite to 3rd molar respec-
collected for examination. tively.
Antibiotic therapy is preferred to surgical Submandibular lymphadenopathy and
intervention. lymphadenitis.
4. Mediastenitis
It is an extension of infection from deep neck
spaces into the mediastenum, which is caused
as a very late complication thereby causing chest
pain, dyspnea, unremitting fever and charac-
teristic mediastenal widening in radiograph. The
condition is treated by long term antibiotic
therapy and surgical drainage of mediastenum.
PERICORONITIS
It is a infection of the operculum covering the
partially erupted permanent teeth specially the Fig. 9.14: Clinical view of pericoronitis
mandibular 3rd molar. (For color version see plate 2)
Fig. 9.16: Pericoronitis
Fig. 9.15: Radiographic view of pericoronitis

Fever, malaise, increased pulse rate,

increased respiratory rate, dysphagia.
Sloughing and ulceration of operculum,
halitosis and trismus.
Fistulous tract which may or may not be
draining may be seen.
Treatment
In case of Acute Pericoronitis, general Fig. 9.17: Operculectomy
management of an odontogenic infection -
complete bed rest, soft nutritious diet and
proper oral hygiene with use of mouth rinses,
is advised.
Proper use of antibiotic and analgesic should
be instituted - Penicillin, Doxycycline, and
Metrinidazole is preferred.
Thorough debridement of tissues with
chlorhexidine irrigation and hot saline mouth
wash.
In certain cases, surgical excision of the
operculum - operculectomy (Fig. 9.17) or Fig. 9.18: Postoperative
use of caustic agents or electrocautery with
or without extraction of the offending,
PERITONSILLAR ABSCESS (QUINSY)
opposing maxillary tooth is adivised.
In case of chronic Pericoronitis, proper It is a localized infection of the tissues between
antibiotic and analgesic with or without the tonsils and superior constrictor muscles and
extraction of offending, opposing maxillary between the anterior and posterior pillars of
tooth is recommended. fauces.
Features FURTHER READING

Infection spreads from an acute pericoronal 1. Shafer-Hine-LevyShafers textbook of
abscess which is present near the tonsils or oral pathology, 5th ed. 2006.
from an infection near the supratonsillar 2. Killey HC, Seword GR, Kay LN An
fossa. outline of oral surgery, part I.
Pain near the throat and ear of the affected 3. Topozian RG, Goldberg MGoral and
side. maxillofacial infection, 3rd ed 1999.
Fever, dysphagia, trismus, drooping of saliva, 4. Peterson, Ellis Hupp, TuckerContem-
altered speech, and difficulty in swallowing. porary oral and Maxilllofacial Surgery, 4th
ed, 2006.
Treatment 5. Danier M LaskinOral and Maxillofacial
surgery. The biomedical and clinical basis
General management of an infection with soft
for surgical practice. Vol. 2.
diet and proper antibiotics and analgesics are
6. Archer WHOral and maxillofacial surgery,
recommended. Surgical drainage by an incision
5th ed. vol. 1.
into the most prominent part of the soft palate
to drain the abscess.
If not treated properly severe oedema
affecting the tongue and epiglottis may occur
which may even lead to death.
Inflammatory Disease
of Jaw Bone
10
OSTEOMYELITIS OF JAW Etiology
Definition i. Contigenous spread of odontogenic

infection
It is a diffuse inflammation of the soft tissue and
bone involving the cancellous bone marrow and
the periosteal component. Osteomyelitis can also
be defined as an inflammation of the medullary
portion of the bone.
Osteomyelitis can be explained as an
inflammatory condition of bone that begins as
an infection of the medullary cavity and
haversian systems and extends to involve the
periosteum of the affected area.
Classification
Suppurative Non-suppurative
Osteomyelitis Osteomyelitis
i. Acute suppurative i. Chronic sclerosing
osteomyelitis osteomyelitis
ii. Chronic suppurative ii. Focal sclerosing osteomyelitis
osteomyelitis iii. Diffuse sclerosing osteomyelitis
Primary iv. Garre's sclerosing
Secondary osteomyelitis
iii. Infantile osteomyelitis v. Actinomycotic osteomyelitis
vi. Radiation osteromyelitis
and necrosis
ii. Trauma and injury leading to compound
fracture of teeth.
iii. 2.
iv. Laceration and infections of the lymph node

leading to osteomyelitis via hematogenous
spread.
Osteomyelitis is more commonly seen in
patients with reduced host resistance, altered jaw The microorganisms causing osteomyelitis
vascularity or those suffering from systemic are mainly of staphylococcus species, and
diseases. -hemolytic streptococcus species. Besides these
peptostreptococci, fusobacterium and prevotella
Pathogenesis species are also involved, thus mixed bacterial
Osteomyelitis is initiated from a contiguous focus cultures are seen.
of infection or by hematogenous spread. Any
condition leading to the avascularity of the
Clinical Features
medullary portion of the bone can lead to the Clinically osteomyelitis is of four types:
occurrence of osteomyelitis in that particular i. Acute suppurative osteomyelitis
bone. ii. Secondary chronic osteomyelitis - Begins
Among the jaws, osteomyelitis is mostly seen as acute and progresses to chronic
in the mandible as-- iii. Primary chronic osteomyelitis - Has no acute
Maxilla is more porous and richly supplied phase and shows low grade infection
by blood vessels. iv. Non-suppurative osteomyelitis.
Maxilla has thin cortical plates and paucity
of medullary tissues due to which any i. Acute suppurative osteomyelitis is
maxillary infection remains confined within characterized by:
the bone and the edema and pus dissipates a. Deep intense pain
into the soft tissues and sinuses. b. High intermittent fever
There are two sequelaes which have been c. Parathesia or anesthesia of lower lip
proposed for describing the pathogenesis of d. A clear identifiable cause, usually deep
osteomyelitis. caries in the involved tooth.
1. e. Increased temperature and malaise.
f. No radiographical findings
g. Edema and tenderness of overlying tissue.
If disease is not controlled by empirical
antibiotics within 10-14 days, it leads to
established suppurative osteomyelitis and
following findings are seen.
1. deep pain, malaise, fever (101-102F),
anorexia.
Inflammatory Disease of Jaw Bone 139
2. Teeth begin to loosen and become sensitive Scintigraphy or bone imaging or radionuclide
to percussion scanning is a new diagnostic tool used to
3. Pus exudates around gingival sulcus and determine the presence of reactive bone. 99mTc-
through mucosa or cutaneous fistula. labelled phosphate compounds are given I.V to
4. Fetid oral odour distribute to the entire skeleton and concentrate
5. Firm cellulitis of cheek, abscess formation with in areas of increased blood supply and reactive
localized warmth, erythema, tenderness on bone. Rectilinear scanner or scintiliation camera
palpation and mental nerve parasthesia; is used to image technetium. The image obtained
expansion of the bone due to increased is used to reveal the distribution of radionuclide
periosteal activity. in areas of increased bone activity. This technique
6. Regional lymphadenopathy. distinguishes reactive bone from the normal
ii. Secondary chronic osteomyelitis is bone but is unable to distinguish between the
characterized by: reactive bone associated with osteomyelitis and
a. Minimal pain other conditions like fibrous dysplasia. However,
b. Presence of fistula. scintigraphy can confirm a diagnosis of very early
c. Induration of soft tissue osteomyelitis before any radiographic bone
d. A thickened or 'wooden' character to the changes have occurred.
affected area with pain and tenderness
on palpation. Treatment
iii. Primary chronic osteomyelitis is charac-
terized by: Principles of Treatment of Osteomyelitis
a. Insidious onset with slight pain.
b. Slow increase in jaw size 1. Evaluation and correction of host defense
c. Gradual development of sequestra, often deficiencies
without fistula. 2. Gram staining, culture and sensitivity
3. Imaging to rule out bone tumor.
Investigations 4. Administration of stained - guided empirical
antibiotics.
In acute stage osteomyelitis cannot be diagnosed 5. Removal of loose teeth and sequestra to
using radiograph as there is less of mineralized decrease the number of bacteria.
bone destruction occurred. 6. Administration of culture guided antibiotics;
In chronic stage, the following characteristic repeated cultures.
features are seen in a radiograph:
7. Possible placement of irrigation drains/
a. Moth-eaten appearance of the bone involved
polymethyl methacrylate - antibiotic beads.
because of enlargement of medullary and
8. Sequestrectomy, debridement, decortication,
widening of Volkmann canal, secondary to
resection, reconstruction (surgical manage-
destruction by lysis of bone and its
ment)
replacement with granulation tissues.
b. Sequestra formation due to bone destruction
Antibiotic Therapy for Osteomyelitis
and islands of involcrum or new bone seen.
c. Granular dense bone formed due to Appropriate use of antibiotics depends on the
subperiosteal deposition of new bone and stage of disease, host defense and ability to
this central sequestra formed helps to obtain materials for lab diagnosis.
distinguish osteomyelitis from fibrous Antibiotics of importance in the treatment of
dysplasia. osteomyelitis are Penicillin, Penicillinase resistant
Penicillin, combination of both penicillin, prevent the further spread of infection. Pus
clindamycin, cephalosporin and erythromycin. drainage from the bone can be accomplished
Recommended antibiotics for osteromyelitis by:
treatment are: a. Opening up the pulp chamber
b. Making fenestration through cortical plate
Early Empirical therapy Aqueous penicillin,
over apical area.
2 million units, I.V 4th hourly until symptoms
c. Making an incision and opening a window
have subsided for 48-72 hours, switch to
over the alveolar crest, especially in case of
penicillin V, 500 mg P.O, 4th hourly for 2-4 week.
edentulous posterior maxilla.
Initial therapy after staining If smear suggests d. Making a small incision over the point of
of staphylococcus infection - Oxacillin 1 gm, I.V greatest tenderness or below mandible in case
4th hourly until symptoms have subsided for of osteomyelitis of ramus or angle of
48-72 hours, then switch to Dicloxacillin 500 mandible.
mg, P.O, 6th hourly for 2-4 weeks.
If smear suggests of anaerobic infection- Sequestrectomy With or
Aqueous penicillin 2 million units I.V 4th hourly Without Saucerization
until symptoms have subsided for 48-72 hours
then switch to penicillin V, 500 mg, P.O 4th Sequestrectomy is the removal of the sequestra
hourly for 2-4 weeks. to prevent the spread of infection and minimize
tooth mobility (Fig. 10.1).
For penicillin allergic patients Clindamycin, Sequestra are cortical or cortico - cancellous
600 mg, I.V 6th hourly then switch to bone generally formed 2 weeks after the onset
clindamycin, 300-450 mg, P.O, 6th hourly OR of infection and are avascular bony fragments
Cefazolin 500 mg I.V or I.M 8th hourly then which are poorly penetrable by antibiotics and
switch to cephalexin 500 mg P.O 6th hourly. are highly susceptible to pathologic fracture. To
prevent high instances of fracture, spread of
Surgical Management of Osteomyelitis infection and hasten healing, sequestrum is
Initially in acute stage only removal of very loose surgically removed.
teeth and bony fragments as well as incision and Saucerization is the excision of the margins
drainage of fluctuant area is indicated. of necrotic bone overlying an osteomyelitis which
In chronic stage further surgical intervention will allow visualization of sequestra before
is indicated, like removal (Fig. 10.2). This procedure is performed
i. Sequestrectomy with or without sauceri- immediately after the acute stage and is rarely
zation. done in maxilla as oro-antral fistula can result.
ii. Decortication
iii. Resection followed by reconstruction. Along Procedure
with this Hyperbaric oxygen therapy (HBO)
Reflection of the buccal flap of the affected
is used as an adjuvant to hasten healing.
region to expose bone.
Remove the loose teeth.
Incision and Drainage Buccal plate is reduced by rongeurs to
Intraoral or extraoral incision is carried out to produce saucer like defect.
relieve the patient of the pain and pressure Granulation tissue and debris are removed
caused by the accumulation of pus and also and the area is thoroughly irrigated.
The buccal flap is trimmed and medical pack Reflection of the mucoperiosteum.
(iodoform gauge and antibiotic pack) is put Removal of the involved tooth.
to promote healing. Removal of lateral cortical plate and the
Pack is maintained by sutures until bone inferior border, 1-2 cm beyond the affected
margin is healed. area to provide access to the medullary cavity
(Fig. 10.3).
Thorough debridement of the tissues and flap
closure.
Irrigation tube may be placed through
separate cutaneous stab incisions and closed
irrigation suction may be employed.
Fig. 10.1: Sequestrectomy
Fig. 10.3: Decortication
Resection Followed By Reconstruction

This is an aggressive procedure indicated during
Fig. 10.2: Saucerization
the following conditions:
Pathological fracture
Persistent infection after decortication
Decortication Marked disease of both cortical plates.
Decortication is the removal of chronically Osteotomy is performed by an intraoral route
infected cortex of bone. It is done during the and immediate reconstruction is done using a
subacute or chronic stage of infection thus block of cancellous iliac crest bone or cancellous
removing the avascular infected cortical bone. marrow which is stabilized with titanium mesh,
Decortication is done in conditions where the thus helping in rehabilitation of the region.
initial conservative treatment has failed and also
as an initial treatment of primary and secondary Complications During
chronic osteomyelitis. Surgical Management
Bleeding
Procedure Injury to inferior alveolar nerve
Reflection of the buccal flap of the affected Pathological fracture
region. Discontinuity defect
TYPES OF OSTEOMYELITIS Mostly associated with infected pulp of

mandibular molars or premolars.
Garre's Osteomyelitis Clinically the lesion is generally asymptomatic
(Chronic osteomyelitis with proliferative with no or mild signs of pain.
periostitis, chronic non-suppurative sclerosing Radiographically, a circumscribed radiopaque
osteomyelitis, periosteitis ossificians) mass of sclerotic bone with distinct or
It is a focal gross thickening of the periosteum indistinct margins is seen associated with the
with periapical reactive bone formation caused affected tooth roots.
due to mild irritation or infection. Histologically, a dense mass o bony
trabaculae with little interstitial marrow, soft
Features tissues and lymphocytes is seen.
Treatment is best achieved by endodontic
Mainly seen in children and young adults. therapy or extraction of the infected tooth.
Mostly associated with carious mandibular 1st A similar condition is seen which is diffused
molar but occasionally there may be no or multiple in form and is known as chronic
dental etiology. diffused sclerosing osteomyelitis. This
Clinically, a localized, hard, non tender, bony condition is treated by surgical sequestrec-
swelling of the lateral and inferior aspect of tomy and debridement, decortication or
the mandible is seen. resection with reconstruction and adjuvant
Radiographically a characteristic 'ONION antibiotic therapy.
SKIN' appearance is seen formed by the
laminated, smooth, focal, calcified bone Infantile Osteomyelitis
proliferation.
Staphylococcus areus and Staphylococcus This is an uncommon condition associated with
epidermidis are the chief micro-organisms infants but deserves a special care due to the
associated. potential facial deformities resulting from delayed
Treatment is best achieved by removing the or inappropriate treatment.
potential source of inflammation by
endodontic therapy or extraction of the Features
tooth involved. Antibiotics may not be Infantile osteomyelitis is caused due to
administered unless infection is present and hematogenous spread of infection from
post treatment follow-up is essential. mother, perinatal trauma of oral mucosa,
infections of maxillary sinus or contaminated
Condensing Osteitis (Chronic focal human or artificial nipples.
sclerosing osteomyelitis) Mostly seen in infants a few weeks after birth
and mainly maxilla is affected.
It is an unusual reaction of bone to infection
Clinically, a facial cellulitis is present about
occurring in instances of extremely high tissue
the orbit. Patient also shows fever, malaise,
resistance or in cases of low grade infections
irritability, dehydration, anorexia, convulsion,
palpebral edema, conjunctivitis, sinusitis and
Features
vomiting.
Usually seen in patients below 20 years of Treatment should be prompt and aggressive
age. to prevent optic damage, neurologic
complications, and loss of tooth buds and purulent material with debridement of
bone. Antibiotic therapy with incision and surrounding tissues. Currently iodides and
drainage generally surfise as the management. radiotherapy are also used effectively.
Occasionally sequestrectomy may be
necessary. OSTEORADIONECROSIS
Actinomycotic Osteomyelitis Definition

It is a chronic infection manifesting both It is a chronic, nonhealing wound caused by
granulomatous and suppurative features that hypoxia, hypocellularity and hypovascularity of
usually involve soft tissue and occasionally bone irradiated tissues.
of the cervicofacial, abdominal and thoracic
region. Pathogenesis
It is a radiation induced, nonhealing and hypoxic
Features
wound rather than true osteomyelitis of
Clinically actinomycosis is of four types: irradiated bone.
Cervicofacial (most common)
Radiation more than 5000 rad to jaws
Abdominal

Thoracic
Death of bone cells
Cutaneous.

Actinomycosis is caused due to an
Obliterative arteritis (arteritis with
infection of a gram positive filamentous
hyalinization, fibrosis and
bacteria- Actinomycosis Israelli,
thrombosis of vessels)
Actinomycosis viscosus, Actinomycosis

odontolyticus in patients with trauma,
Aseptic necrosis of bone directly in beam of
dental caries or other hypersensitive
radiation and having compromised
reactions.
vascularity of adjacent bone and soft tissue.
Clinically, a firm, soft tissue mass which
is oily, purplish or dark red is seen on the
Mandible is more commonly affected than
skin. Small fluctuant areas which may
maxilla as--
show spontaneous drainage of serous
most old tumors are perimandibular
fluid containing granular material may
dense cortical plates are absent in maxilla.
occur.
Extensive vascular network is present in
Regional lymphadenopathy is common.
maxilla.
Radiographically, a radiolucensy is seen
associated with delayed healing of
Clinical Features
extracted site.
Histologically the yellow granules shows Severe deep pain continuing till weeks or
closely packed branching filamentous months
colonies. Presence of soft tissues abscess or draining
Treatment is best achieved by a combi- sinus and fistula
nation of antibiotic therapy and surgery Exposed bone with abraded and ulcerated
involving incision and drainage of the soft tissue (Fig. 10.4)
Facial swelling is present when infection 5. Maintaining post-irradiation dental health

develops a. extraction is contraindicated for 6-9
Trismus months
Fetid odour b. Dentures should not be worn for 1 year
Pyrexia c. Salivary substitutes are advised because
Pathological fracture. of xerotomia.
Radiographically, there is hardly any changes d. Endodontic treatment is indicated for
seen as sequestra and involucra formation post irradiated pulpitis and not extraction.
is not seen or seen late in an irradiated bone If extraction is at all necessary then
because of severely compromised blood should be done under proper care and
supply. for 1-2 teeth only.
Treatment steps to be followed:
i. Administration of antibiotics (penicillin and
metrinidazole), analgesics and supportive
therapy with fluid, high protein and vitamin
diet.
ii. Irrigation of exposed bone and soft tissue
margin.
iii. Mechanical debridement and smoothening
of bone using bone files and burs, and
medicated dressing with zinc peroxide and
neomycin.
Fig. 10.4: Clinical view of osteoradionecrosis involving
the mandible (For color version see plate 3) (irrigation and medicated dressing is re-
peated weekly until sequestra has occurred
Management or bone is penetrated by granulation
tissues).
Prevention of Osteoradionecrosis iv. Series of holes are drilled perpendicular to
1. Use of megavoltage commonly obtained lingual cortical plate to the depth at which
from cobalt teletherapy units, instead of the bleeding bone is encountered. This method
use of orthovoltage in radiotherapy units. was used earlier to encourage revasculari-
2. Dose fractionation zation of the bone (ultrasound therapy)
3. Collimation to shield normal tissues v. Hyperbaric oxygen therapy with or without
4. Maintaining pre-irradiation dental health bone resection.
a. extraction of teeth 2-3 weeks before Generally patients are treated for
radiation therapy done with alveolo- osteomyelitis as outpatients but hospitalization
plasty. may be required for patients who shows toxic
b. Restoration of dental caries and symptoms and are dehydrated to permit
periodontal health supervised administration of antibiotics and
c. Fluoride application fluids.
Proliferation of granulation tissues

Enhances arterial and venous oxygen
tension.
Enhances sequestra formation and replace-
ment of devitalised bone.
Fig. 10.5: Mechanism of HBO therapy

Indications
Osteoradionecrosis
Refractory chronic suppurative osteomyelitis
Refractory chronic sclerosing osteomyelitis
Diffused sclerosing osteomyelitis
Contraindications
Optic neuritis
Immunosuppressive diseases.
HYPERBARIC OXYGEN THERAPY
(A PROCEDURE USED AS AN
ADJUVANT TO SURGERY)
It is a process of breathing 100 percent oxygen
at 2.4 atmospheric pressure for 90 mins/dive,
5 days/week. Totalling 30 sessions (Marx
protocol)
Mechanisms
Bacteriostatic affect on microbes
Induces neo-angiogensis
Fibroblast proliferation under increased Fig. 10.6: Hyperbaric oxygen therapy unit
oxygen tension (For color version see plate 3)
Helps in fistula closure.

Clinical and radiological healing
Enhances bone graft osteogenesis.
FURTHER READING
1. Archer WH Oral and maxillofacial surgery, 5th
ed, vol. 1.
2. Gustav O Kruger Textbook of oral and
maxillofacial surgery, 16th ed.
3. Peterson, Ellis, Hupp, Tucker Contemporary
Fig. 10.7: Patient under treatment in small unit
oral and maxillofacial surgery, 4th ed, 2006.
4. Shafer-Hine-Levy Shafers textbook of oral
Advantages pathology, 5th ed, 2006.
5. Topazian RG, Goldberg MG Oral and
Decreases pain maxillofacial infection, 3rd ed, 1994.
Decreases trismus and increases patient 6. White and pharaoh Oral radiology, principles
comfort. and interpretation, 5th ed, 2006.
Surgical Procedures in
Prosthodontics 11
Preprosthetic Surgery
Preprosthetic surgery are the surgical procedures iii. Reduction of maxillary tuberosity
carried out to reform or redesign denture bearing iv. Reduction of genial tubercle.
areas to create an oral environment to support v. Reduction of mylohyoid ridge.
a functional prosthetic appliance. 2. Soft tissue correction:-
i. Frenectomy
Aims of Preprosthetic Surgery a. Labial frenectomy
1. Provide adequate bony tissues for prosthesis b. lingual frenectomy
support (Ridge height and width) c. Buccal frenectomy
2. Provide adequate soft tissue support ii. Removal of crestal soft tissue
3. Eliminate pre-prosthetic bony deformities iii. Removal of epulis fissuretum or fibrous
(Tori, Exostosis) hyperplasia or denture fibrosis.
4. Correction of maxillary and mandibular ridge
relation II. Ridge Extension Procedures:
5. Relocate abnormal frenum and muscle (Vestibuloplasty or sulcoplasty
attachment or sulcus deepening procedures)
6. Relocate mental nerve
7. Establishing correct vestibular depth. 1. Maxillary procedures:
i. Secondary epithelization technique
Classification of Preprosthetic Surgery ii. Sub mucosal technique
iii. Grafting technique
I. Ridge Correction Procedures
2. Mandible procedures:
1. Hard tissue correction: i. Buccal or labial approach
i. Alveoloplasty ii. Lingual approach
a. simple alveoloplasty iii. Labial and lingual approach (floor of the
b. single tooth alveoloplasty mouth lowering procedure)
c. radical alveoloplasty
d. interadicular alveoloplasty or III. Ridge Reconstruction or Augmentation
interseptal alveoloplasty Procedures
ii. Excision of tori
a. maxillary tori excision 1. Ridge reconstruction with non-resorbable
b. mandibular tori excision. hydroxyapetite (onlay grafts)
2. Ridge augmentation with iliac crest bone or I. RIDGE CORRECTION PROCEDURES

rib bone graft.
3. Ridge augmentation using osteotomy 1. Hard Tissue Procedures
technique:- i. Alveoplasty or Alveolectomy: It is a process
i. Interpositional bone graft of surgically removal of a portion of the
ii. Sinus lift procedure alveolar bone or shaping of alveolar ridge.
iii. Augmentation with orthognathic surgery This procedure is mostly done after
iv. Visor osteotomy procedure multiple extraction or on uneven ridges
v. Sandwich osteotomy procedure with a goal of conservation of maximum
4. Implants for ridge reconstruction amount of bone consistent with a good
i. Endosteal implants ridge. The most conservative procedures is,
ii. Subperiosteal implants compression of the alveolar wall by finger
iii. Transosteal implants and thumb pressure.
ii. Excision of tori: A tori is a benign outgrowth
present only the mid-palatal suture of
CHARACTERISTIC OF
maxilla (maxillary tori) or along the lingual
AN IDEAL RIDGE FOR surface of mandible (mandibular tori).
BEST DENTURE SUPPORT These are removed to increase denture
They are: retention and stability. Proper clinical and
1. No evidence of intraoral or extraoral Radiographic evaluation should be done
pathologic conditions. prior to surgery to rule out pneumatization
2. Proper interarch jaw relationship in the of tori (to prevent formation of oro-antral
fistula) in case of maxilla and nearness to
anteroposterior, transverse and vertical
mandibular canal (to prevent damage to
dimensions.
nerve bundles) in case of mandible.
3. Alveolar process that are as large as possible
iii. Reduction of maxillary tuberosity: Maxillary
and of the proper configuration. ( The ideal
tuberosity is the bulbous extension of the
shape of the alveolar process is a broad U-
residual ridge in the upper second and
shaped ridge with the vertical components
upper third molar region. In certain cases
as parallel as possible)
this tuberosity is excessively enlarged (either
4. No bony or soft tissue protuberances or fibrous enlargement or bony enlargement)
undercuts. and is better to be reduced to increase
5. Adequate palatal vault form. intermaxillary space in the posterior region
6. Proper posterior tuberosity notching and make the ridge regular. Proper
7. Adequate attached keratinized mucosa in preoperative investigations should be done
the primary denture bearing area. to differentiate between fibrous or bony
8. Adequate vestibular depth for prosthesis enlargement and to rule out nearness to
extension maxillary sinus, thus prevent formation of
9. Added strength where mandibular fracture oro-antral fistula.
may occur. iv. Maxillary Tuberosity: This is a procedure
10. Protection of the neurovascular bundle. done to increase the depth of the hamular
11. Adequate bony support and attached soft notch and the distal aspect of maxilla in case
tissue covering to facilitate implant of flat maxillary ridge, thus preventing
placement when necessary. anterior displacement of the denture.
Surgical Procedures in ProsthodonticsPreprosthetic Surgery 149
Types of Alveoplasty and Their Procedures

a. Simple b. Single tooth c. Radical d. Interradicular or
- here, buccal alveolar - done following - here complete labial Interseptal
plates and removal of isolated plate is removed - here the interradicular
interseptal posterior tooth to in cases of extreme bone is removed
bone is removed. Reduce the prominent undercut, in cases of
prominent buccal skeletal horizontal prominant premaxilla
cortical undercut. jaw discrepancy or or skeletal class II
in preradiation therapy disproportion
Fig. 11.1 Fig. 11.2 Fig. 11.3 Fig. 11.4
Maxillary Torus Removal Mandibular Torus Removal
Fig. 11.5 Fig. 11.6
Maxillary Tuberosity Reduction

Bony enlargement Fibrous enlargement
Incision extended along crest of alveolar ridge Elliptical incision around soft tissue
Step 1 Step 1
Reflection of flap Reduction of bone and Soft tissue excised Soft tissue closure
Step 2 reposition of flap Step 2 Step 3
Step 3
Fig. 11.7 Fig. 11.8
Maxillary Tuberoplasty
Decreased depth of hamular notch

in posterior maxillary ridge Fracture line of plerygoid plate
Step 1 Step 2
Flap suture at sulcus depth for

Pterygoid plate pushed posteriorly increase depth of hamular notch
Step 3 Step 4
Fig. 11.9
2. Soft Tissue Correction This procedure also increases the mobility of

the tongue (In case of high mandibular lingual
i. Frenectomy: Frenum is a fibrous band of
frenum, ankylosis of tongue occurs) and
tissue present on the maxilla and the
improves the esthetics of the patient.
mandible which connects the lip or the
a. Labial Frenectomy
tongue to the jaw. Frenectomy is the surgical
b. Lingual Frenectomy
removal of the excessively high frenum to
increases denture stability.
a. Labial Frenectomy b. Lingual Frenectomy

After proper anesthesia we retract lip using a forcep After proper anesthesia we retract the tongue using
or traction suture and apply two hemostats on either a forcep or traction suture and apply two hemostats
side of the frenum. on either side of the frenum.
High labial frenum High lingual frenum

Condition Condition
2 cross diamond shaped incision placed 2 cross diamond shaped incision placed and
Step 1 submucosa undermined
Step 1
Suturing done Suturing done

Step 2 Step 2
Fig. 11.10 Fig. 11.11
Frenoplasty: This is the procedure of incising the frenum and suturing it back to a new position
to alter it structure.
Small elliptical incision on the mucosa Two incision placed

Step 1 Step 2
Flaps reflected Flap rotated and sutured

Step 3 Step 4
Fig. 11.12
iii. Removal of epulis fisseratum or fibrous alveolar ridge and vestibular area mostly due
hyperplasia or denture fibrosis. to illfitting dentures. The conditions are mostly
Epulis fisseratum or fibrous hyperplasia or treated by conservatively by relieving the area
denture fibrosis is a generalized hyperplastic and soft tissue liners. In certain severe cases
enlargement of mucosa and fibrous tissue in the surgical treatment is also done.
(A) Large area of inflammatory (B) Flap sutured to the periosteum

fibrous hyperplasia at the depth of the vestibule
Fig. 11.13
II. RIDGE EXTENSION PROCEDURE 1. Maxillary Procedures

(VESTIBULOPLASTY/SULCOPLASTY)
i. Submucosal technique (Obwegeser)
Vestibuloplasty is the uncovering of existing basal ii. Grafting technique (combined pedicled
bone of jaw surgically by repositioning the mucosal transposition flap and skin graft).
overlying mucosa, muscle attachment and
muscle to a lower position in mandible or to a
superior position in maxilla.
(i) Submucosal technique (Obwegeser) (ii) Grafting technique
Excess submucosal tissue layer Incision placed

Step 1 Step 1
Excision of soft tissue layer Flap reflected soft tissue excised

Step 2 Step 2
Holding mucosa in place Skin graft placed along with splint

Step 3 Step 3
Fig. 11.14 Fig. 11.15
2. Mandibular Procedures
i. Buccal or labial approaches: This is the process of increasing the vestibular depth of the labial
side. The various procedures for this are:
a. Transpositional flap b. Modified Lip Switch c. Submucosal technique
Vestibuloplasty or technique (Obwegeser's)
Lip Switch (Edlan)
(Kazanjian)
Step 1 Step 1 Step 1
Step 2 Step 2 Step 2
Fig. 11.16 The technique overcomes the Fig. 11.18

drawback of the lip switch techni-
que of scar formation and long
term post-operative pain
Fig. 11.17
ii. Lingual approaches:

a. Lingual sulcus extension b. Lingual ridge extension
(Trauner) (Caldwell)
- Here mylohyoid muscle is repositioned. - Here full thickness mucoperiosteum is Dissected.
Step 1 Step 1
Mylohyoid muscle positioned lower and Mylohyoid ridge

circumferential tie placed to hold muscle excision is done
Step 2 Step 2
Split skin graft Flap repositioned and mylohyoid

placed on bone muscle held by circumferential tie
Step 3 Step 3
Fig. 11.19 Fig. 11.20
iii. Labial and lingual approach:

(Floor of mouth lowering procedureObwegeser)
Fig. 11.21
III. RIDGE RECONSTRUCTION OR

AUGMENTATION PROCEDURES
These are procedures to increase the alveolar
ridge height in case where the ridge has fully
resorbed and other methods like vestibuloplasty
has failed.
Indications
1. Gross atrophy of alveolus and possibility of Fig. 11.22: Injection of hydroxyapetite
further resorption. into subperiosteal tunnel
2. Localized severe alveolar ridge defects
following surgery 2. Migration of hydroxyapetite particles.
3. Young patients with severe jaw atrophy 3. Abrasion of mucosa and extrusion of particles
4. Atrophic maxilla causing prosthetic difficulty. 4. Infection
Graft Materials Used For Augmentation 5. Abnormal colour over ridge.
6. Mental neuropathy.
1. Autografts/autogenous bone grafts:
i. Iliac crest bone (commonly used) 2. Ridge augmentation with iliac crest
ii. Rib bone (Vth and VIIth rib) bone or rib bone graft
2. Alloplastic bone graft material: This technique is used to overcome the
i. Hydroxyapetite (non- resorbable) complication of bone resorption and graft
ii. Tricalcium phosphate (resorbable) extrusion of only bone graft procedure.
3. Allogenic bone graft i. Superior border augmentation technique
i. Freeze dried bone grafts
ii. Surface decalcified freeze dried bone grafts.
4. Xenograft materials
i. Bio-oss (bovine)
Procedures used for Reconstruction
or Augmentation
1. Ridge reconstruction using non-
resorbable hydroxyapetite materials Fig. 11.23: Superior border grafting of atrophic
(only grafts). mandible held by plates and screws
Techniques
ii. Inferior border augmentation technique
After instituting proper local anesthesia a midline
incision (for maxilla) or bilateral vertical
mucoperiosted incision (for mandible) is done
on the ridge and a subperiosteal tunnel is made.
Hydroxyapetite graft material is inserted and
held in position by sutures followed by splint
(Fig. 11.22).
Complications
1. Dehiscence with extrusion of hydroxyapetite Fig. 11.24: Inferior border grafting done
particles. and held by plates and screws
3. Ridge augmentation using osteotomy

technique
i. Interpositional bone graft ii. Sinus lift procedure.
Fig. 11.25: Graft and maxilla is stabilized Fig. 11.26: Sinus lift
using rigid fixation plates
iii. Augmentation with orthognathic surgery:
(A) (B)
Fig. 11.27: Mandibular sequential osteotomy to reposition molar tooth to function
iv. Visor osteotomy procedure: Here the lingual bone is raised and adapted to the remaining
mandible (Figs 11.28A and B).
(A) Vertical osteotomy procedure (B)

Fig. 11.28
v. Sandwich osteotomy procedure: This is a combination of horizontal osteotomy in the anterior

region and vertical osteotomy in the posterior region (Figs 11.29A to C).
(A) (B) (C)

Fig. 11.29: Sandwich osteotomy procedure
4. Implants for ridge reconstruction

A dental implant is a biologic or alloplastic biomaterial, surgically inserted into the soft tissue
or hard tissue of mouth for functional or cosmetic purposes.
Classification of Dental Implants

I. Depending on usuage:
1. Endosteal implants
i. Root form implants
a. Cylinder type
b. screw type.
ii. Plateform implants (blade)
2. Subperiosteal implants
3. Transperiosteal implants.
(A) Subperiosteal (B) Transosseous (C) Cylinder (D) Plate Form
Fig. 11.30: Types of dental implants
II. Depending on the material used: 3. The mean vertical bone loss is less than 0.02
1. Metal and alloy mm annually after the first year of service.
i. Titanium 4. No persistent pain, discomfort, or injection
ii. Stainless steel is attributable to the implant.
iii. Chromium - cobalt - molybdenum alloy 5. The implant design does not preclude
iv. Gold plated placement of a crown or prosthesis with an
2. Ceramic/porcelain appearance, that is satisfactory to the patient
i. Bioactive glass and the dentist.
ii. Hydroxyapetite (HA)
iii. Aluminum oxide Biological Consideration in Implant -
3. Composite/resin Tissue Interface
i. Polymethylmethocrylete
1. Soft tissue - implant interface reactions: The
ii. Polyethylene
collagen fibres at the junctional epithelium-
iii. Polypropylene
implant interface runs at right angle forming
iv. Silicon
a tight cuff of fibrous connective tissue which
4. Carbon implants
supports the epithelium seal and forms an
effective barrier to peri-implant pocket
Indications of Implants
formation and bone loss.
1. Edentulous patients 2. Bone - implant interface reactions:
2. Ridge resorbed cases i. Fibro-osseous integration: It is the presence
3. Multiple missing teeth of healthy dense collagenous tissue between
4. Single missing tooth the bone and implant. In this conditions the
5. Patient's desire fibres run irregularly parallel to the implant
6. Severe parafunctional habits. body and thus this interface shows a very
7. Poor oro-muscular coordination low success rate.
ii. Osteointegration: It is a direct structural and
Contraindications of Implants functional contact between living bone and
1. Acute illness a load carrying implant. This condition is
2. Terminal illness similar to ankylosis and provides a high
3. Pregnancy success rate. The factors needed for this are:
4. Uncontrolled metabolic disease - biocompatible material choice
5. Turoricidal radiation to the implants site. - Implant precisely adapted to prepared
6. Unrealistic expectation bone site.
7. Improper motivation - Atraumatic surgery to minimize soft tissue
8. Lack of operator experience. damage.
9. Unable to restore prosthodontically. - Immobile, undisturbed healing phase.
Implants Success Criterias Techniques of Implant Surgery

1. The individual unattached implant is 1. Endosteal implant insertion
immobile when tested clinically. i. One- stage or single insertion procedure:
2. No evidence of periimplant radiolucency is Here, implant is placed in the jaw with the
present, as assessed on an undistorted prosthetic part of the implant extruding onto
radiograph. the oral cavity. The implant is stabilized in
its position by implant splint for avoiding

occlusal forces on the implant during the
healing phase (Fig. 11.31).
Fig. 11.33: Two stage procedure: Healing cap

(Second stage)
Fig. 11.31: One stage procedure
ii. Two-stage procedure: Here, multicompo-

nent implant is used. During the first surgery
the implant body is inserted into the jaw
and covered fully with the mucoperiosteum
(Fig. 11.32), for six week to allow osteo-
Fig. 11.34: Two stage procedure: Implant-
integration to take place. After six weeks
impression post (second stage)
the mucoperiosteum is again reflected to
expose the implant and the prosthetic
component is now fixed to it (Figs 11.33
and 11.34).
Fig. 11.32: Two stage procedure: Sealing screw Fig. 11.35: Two-stage root form
(First- stage) endosteal implants
Comparison of Screw Type and 3. Transosteal impression insertion

Cylinder Type Endosteal Implants This is an extraoral method and is done under
general anesthesia. Holes are drilled on the lower
Screw type (threaded) Cylinder type (press - fit) border of the mandible and implant is placed
to reach the intraoral site over the ridge.
Turned into the site A press - fit implant has
within the bone smooth walls and is topped
following preparation into the site. Potential Problems With Tooth
of the site. and Implant Supported
30-500 percent greater Less surface are, less Fixed Partial Dentures
surface area than contact area.
1. Breakdown of osseointegration
cylinder type, thus
greater bone contact
2. Cement failure on natural abutment.
Requires greater A cylinder implant may be
3. Screw or abutment loosening
force for placement. pressed into the bone by 4. Failure of implant prosthetic component.
hand in hard and soft bone.
Complications of an Implant
1. Periimplantitis: It is an inflammatory reaction
Advantages of Two-stage with loss of supporting bone in the tissue
Osteointegrated Cylinder Implants surrounding a functioning implant. This is
caused due overloading an oral implant or
1. Surgical: due to microbial invasion in the area or due
i. Documented success rate. to poor host resistance.
ii. In-office procedure.
iii. Adaptable to multiple intraoral locations. Features
iv. Precise implant site preparation. Saucer-shaped vertical bone loss
v. Reversibility in the event of implant failure. Periimplant pocket formation
2. Prosthetic: Bleeding and suppuration on probing
i. Multiple restorative options. Inflammatory features of swelling, redness
ii. Versatility of second - stage components. and pain in the tissues
a. angle correction Mobility of the implant.
b. esthetic
c. crown contour Management
d. screw - or cement - retained restorations
Mechanical and chemical destruction of the
iii. Retrievability in the event of prosthodontic
microorganisms near the implant.
failure.
Maintaining proper oral hygiene and plaque
2. Subperiosteal implant insertion control.
This method is used for complete ridge or Re-osseointegration done if needed
unilateral ridge reconstruction. 2. Periimplant mucositis: It is a reversible
In this procedure the mucoperiosteal flap is localized inflammation of the soft tissues
reflected and impression is made to fabricate and around the implant caused due to impinging
place a metal framework below the periosteum or irritation caused by the implant. This is
and stabilize it by suturing the mucoperiosteum a reversible condition and required only
over it. supportive treatment.
Indications of Implant Removal 4. Daniel M Laskin Oral and maxillofacial surgery,

1. Severe periimplant bone loss practice, Vol. 2.
2. Bone loss involving implant vents or holes. 5. Day, Girod Oral cavity reconstruction.
3. Unfavourable and advanced bone defects- 6. Forseca, Davis Reconstructive pre-prosthetic
one wall bone defects. oral and maxillofacial surgery, 2nd ed.
4. Rapid, severe bone destruction. 7. Gustav O Kruger Textbook of oral and
5. When non surgical or surgical therapy is
8. Karl Erik Kahnberg Bone grafting technique for
ineffective. maxillary implant.
6. Esthetic area precluding implant surface 9. Misch Dental implant prosthetics.
exposure. 10. Russel Hopkins Pre-prosthetic oral surgery.
11. Stevens, Fredrickson, Gress Implant
FURTHER READING proschodontics - clinical and laboratory
procedures, 2nd ed.
1. Archer WH Oral and maxillofacial surgery, 5th 12. Weiss Principles and practice of implant
ed. Vol. 1. dentistry.
2. Babbush Dental implant, the art and science. 13. Winkelman Orth Dental implant fundamental
3. Block, Kent Endosseous implants for and advanced laboratory technology.
maxillofacial treconstruction.
Endodontics 12
Endodontic Surgery
Endodontic surgeries are the surgical procedures calcifications, anatomic deformity, dila-
performed to remove the causative agent of cerations, instrument obstruction.
periradicular pathosis and to restore the 2. Perforations caused in the canal due to
periodontium to a state of biologic and functional resorption or iatrogenic.
health. 3. Large periradicular disease (abscess)
needing drainage.
Classification of Various Endodontic 4. Need of abscess drainage.
Surgical Procedures 5. Re-implantation of avulsed tooth.
I. Surgical drainage:- 6. Intentional re-implantation.
1. Incision and drainage. 7. Patient's not willing to come for
2. Cortical trephination (fistulative surgery) appointments (less time consulting)
II. Periradicular surgery:- 8. Predicted failure cases.
1. Curettage 9. Numerous failed endodontically treated
2. Biopsy teeth need re-treatment.
3. Root end resection 10. Necessity for diagnostic biopsy
4. Root end preparation and filling 11. Horizontal fracture of root tip with
5. Corrective surgery periapical disease.
i. Perforation repair 12. Need of radisectomy to treat furcation
a. mechanical (Iatrogenic) involvement.
b. resorptive (internal and external) 13. Gross over filling of root canal leading to
ii. Root resection inflammation of periapical tissues.
iii. Hemisection 14. Foreign body or broken instrument in
III. Replacement surgery (extraction/replanta- periapical region leading to inflammation.
tion)
IV. Implant surgery Contraindications
1. Endodontic implants
2. Root from Osseo-integration implant. 1. Medically compromised patients.
2. Emotionally distressed patients.
Indications 3. Limitation of surgeon's skill
1. Conditions in which direct access to apical 4. Local
3rd of canal is obstructed due to i. Localized acute inflammation.
ii. Anatomic considerations (teeth nearing II. Mucoperiosteal flaps (limited)

sinus, neurological bundles, mental canal, This flap does not include marginal and inter
Mandibular canal). dental gingiva.
iii. Inaccessible surgical site (especially posterior a. Submarginal curved (semi lunar flap)
teeth with curved roots). b. Submarginal scalloped rectangular
iv. Teeth with poor prognosis (e.g., short root, (Luebke-Ochsenbein flap).
periodontal disease, vertical fracture, Reflection of flap is done following the
unrestorable teeth). principles of flap design as discussed under
v. Conditions where traumatic occlusion can 'Exodontia'.
not be corrected.
Semi Lunar Flap (Sub-
Classification of Surgical Flaps marginal curved incision)
I. Full mucoperiosteal flaps It is a type of limited mucoperiosteal flaps (Fig.
Includes all gingiva. These flaps are further 12.3).
classified into: Indications
a. Triangular flap (one vertical releasing
incision) (Fig. 12.1). 1. When attached gingiva is to be maintained.
b. Rectangular flap (two vertical releasing 2. There is no pathosis in 2-3 mm from gingival
incision). sulcus.
c. Trapezoidal flap (broad base rectangular) 3. Modified semilunar incision is made to
(Fig. 12.2) preserve labial frenum.
d. Horizontal flap (no vertical incision)
Advantages
1. It is simple and easy.
2. It provides access to the apex without
impinging on tissues.
3. The width of the attached gingiva is
maintained.
4. Better oral hygiene is maintained.
Disadvantages
Fig. 12.1: Triangular flap 1. Visibility is less.
2. There are greater chances of flap margin tear.
3. It can result in dehiscence and scar formation,
if incision is placed over any bony defect.
4. Its use is limited if muscle or any other
prominent structure like canine eminence is
present.
Luebke-Ochsenbein Flap (Sub

marginal scalloped incision)
It is a limited mucoperiosteal flap which was
Fig. 12.2: Trapezoidal flap named after Luebke, an endodontist and
Surgical Procedures in EndodonticsEndodontic Surgery 167
STUDY OF INDIVIDUAL ENDODONTIC

SURGICAL PROCEDURES
I. Apicoectomy with or Without

Retrograde Filling
Apicoectomy also called as root resection or root
amputation. It is the abrasion (cutting off) of the
apical portion of a tooth and curettement of all
periapical necrotic and inflammation tissue (Fig.
12.5).
Indications and contraindications are same
as that of endodontic surgeries.
Fig. 12.3: Semilunar flap
Procedure
Ochsenbein, a periodontist who discovered it. The procedure of apicoectomy can be done in
It is a modified semi lunar flap with scalloped two methods:
horizontal incision and two vertical incision. i. Over orthograde filling followed by
Scalloped incision is placed on the attached apicoectomy, or
gingival parallel to the free gingival groove, and ii. Apicoectomy followed by retrograde filling
should be 3-4 mm short of gingival margin (Fig. The steps of apicoectomy are as follows:
12.4). Radiographs are taken to determine the
length of the root and its approximately to
other structures.
Advantages Administer anesthesia
1. Greater accessibility and visibility. On the labial surface of the tooth, mark with
2. Easy reflected and sutured. the help of a periosteal elevator the root apex,
3. Decreased chances of dehiscence (as there so that incision can be placed.
is decreased chances of placing incision over Place semilunar incision, from apex of the
bony defect). mesial tooth, extending down to 2/3rd of the
4. Marginal gingiva is not affected. infected tooth and then to the apex of distal
The disadvantage is that there is scar tooth (Fig. 12.5).
formation if incision judgment is not proper. Reflect the flap.
Several small openings are made on the labial
cortical plate and the holes are joined to
remove the labial plate.
Root apex is exposed, then cut off the apex
of the tooth with a fissure bur about 1/3rd
of its length.
Curette the surrounding pathologic tissues
and round off the end of the cut root.
For retrograde filling, a bevel of 0- 10 is
given such that it increases accessibility and
Fig. 12.4: Leubke-ochsenbein flap should include all necessary canal (Fig. 12.6).
Retrograde filling of the canal till 3 mm is

done(Fig. 12.7).
Irrigate the wound and suture the flap in
position.
Fig. 12.7: Retrograde filling
Materials used for retrograde filling are:

Earlier used:
1. Amalgam (zinc free)
Fig. 12.5: Apicoectomy 2. Gutta percha (thermoplastic)
3. Gold foil
4. Titanium screw
5. Cavity
6. Polycarboxylate.
Recently used:
1. Glass ionomer cement
2. Zinc oxide eugenol
3. Composite
4. H.E.M.A
5. Bone cement
6. E.B.A
7. MTA (mineral trioxide aggregate)
Post-operative Instructions
Patients should be instructed to follow all
instructions after an extraction along with it, the
following:
1. Do not raise the lip to look at the suture.
2. Place an icepack on the outside of the face
20 min. out of every 1 hour for the first
Fig. 12.6: Angles of apicoectomy day of surgery.
Surgical Procedures in EndodonticsEndodontic Surgery 169
3. Instruct to do salt water rinsing 3 times daily Contraindications

preferably after meal. Poor periodontal condition
4. Do not chew any hard food with the tooth Furcation involvement
for 1 week. Widely divergent or curved roots
5. Do not brush in the area of surgery for Litiguous patients
1 week. Tooth nearing vital structures
6. Maintain good oral hygiene. Poor systemic health of the patient.
7. Soft diet is suggested for the first 4 days.
Procedure
Complications
Two person or operator is required for intentional
They are: replantation.
I. Intra-operative 1st operator - extraction of the tooth and
1. Bleeding by damage to the neighboring care of the wound and socket.
root. 2nd operator - endodontic treatment and
2. Entry into the sinus or inferior alveolar replacement of tooth in socket.
canal. The steps are similar to extraction and
II. Post-operative endodontic treatment with root resectioning.
1. Abscess formation Apicoectomy is performed of 2-3 mm and then
2. Fenestration splinting of the tooth is done. This procedure
3. Sinus tract formation is completed in 15 minutes with periodontal
4. Increased mobility of the tooth. ligament being vital.
INTENTIONAL REPLANTATION BICUSPIDIZATION

It is the intentional removal of a tooth and its It is process in which a tooth is divided into mesial
re-insertion into the socket after orthograde and distal half without removal of any.
obturation and resectioning of the root tip or Endodontic treatment is done and two separate
resection of the root tip followed by retrograde crowns are fixed on both halves. It is performed
obturation, an operation usually limited to in Mandibular molars with furcation involve-
posterior tooth. ment. Better stability of the tooth is achieved
Indications for this procedure are: when there roots are divergent (Fig. 12.8).
A high risk of paraesthesia with standard
apicoectomy techniques because of
approximation of the roots to the inferior
alveolar canal.
Thick external oblique ridge in the molar area
making access difficult or impossible.
Poor access for conventional apicoectomy -
mouth size, a high vestibule or a large bulging
buccal fat pad. (A) (B)
It is a time saving procedure (single sitting). Fig. 12.8: Bicuspidization
ENDODONTIC MICROSURGERY
These are surgical procedures used for small and
complex structures with the aid of an operating
microscopic. The triad of magnification,
illumination and micro instruments provides the
greater accuracy required.
Fig. 12.9: Trephination Sl. Procedure Traditional Microsurgery
No. surgery
HEMISECTIONING 1. Identification of Sometimes Precise

the apex difficult
This process is similar to that of bicuspidization 2. Osteotomy Large Small
except that one half of the tooth is removed ( 10 mm) ( 5 mm)
3. Root surface Imprecise Precise
and the other half is endodontically treated, inspection
which acts as an abutment. 4. Bevel angle Large (45) Small ( 10)
5. Isthmus Nearly Customary
TREPHINATION identification impossible
6. Retro preparation Approximate Precise
Trephination is the creation of a surgical 7. Root end filling Imprecise Precise
passage in the region of the root apex, usually
by a bur or special drill (Fig. 12.9).
The purpose of trephination is to provide a FURTHER READING
channel for the escape of pus and blood to 1. Cohen and Hargreaves Pathways of the pulp,
relieve the pressure of accumulated fluid or 9th ed.
gas in the jaw bone. 2. Daniel M Laskin Oral and maxillofacial surgery,
It has been advocated in: The biomedical and clinical basis for surgical
1. Acute alveolar abscess where drainage is practice, Vol 2.
3. Gustav O Kruger Textbook of oral and
inadequate through root canal. maxillofacial surgery, 6th ed.
2. Teeth with large areas of rarefaction 4. Howe GL Minor oral surgery, 3rd ed.
3. When the root canal has been overfilled and 5. Ingle and Bakland Textbook of endodontics,
pain or discomfort is present 5th ed.
4. For postoperative pain following obturation 6. Peterson, Ellis, Hupp, Tucker Contemporary
of the canal by conventional means. oral and maxillofacial surgery, 4th ed. 2006.
Maxillary Sinus and
Its Disorders
13
Paranasal sinuses are air filled spaces, lined with Roof wall = by orbital surface of maxilla
mucous membrane, within some of the bones Floor = by alveolar process of maxilla.
of the skull. They open into the nasal cavity, via The upper part of the maxillary sinus opens
the meatuses and are named according to the into the middle meatus of the nose via an ostium
bone in which they are situated. They comprise and a thin mucous membrane is continuous
the frontal sinuses and the maxillary sinuses through the aperture of the sinus into the lining
(one pair of each), the ethmoidal sinuses of the nasal fossa.
(consisting of many spaces inside the ethmoidal
bone), and the two sphenoidal sinus (Figs 13.1
and 13.2).
Anatomy of Maxillary Sinus

Maxillary sinus is the largest of all the paranasal
sinuses present within the body of maxilla. It is
pyramidal in shape, with its base directed
medially towards the lateral wall of the nose,
and its apex directed laterally to the zygomatic
process of the maxilla. The boundaries of the
maxillary sinus are:
Medial wall or base = by lateral wall of the
nasal cavity.
Apex = Extends into or beyond the
zygomatic process of maxilla
Anterior wall = by anterior or facial wall of
maxilla
Posterior wall = by infra temporal surface
of maxilla Fig. 13.1: Front view of all paranasal sinuses
1. Proper case history and clinical evaluation

2. Rhinoscopy - Examination of the maxillary
sinus via the nasal cavity using nasal spectrum
and headlights or mirror.
3. Nasoendoscopy - Narrow firbro optic
endoscopes are used.
4. Transillumination test: It is a clinical test to
detect the abnormalities of the maxillary
sinus, but is less confirmatory than
radiographs. Here, a 4 V electric lamp or a
small torch is kept intraorally of the patient
in a dark room and the light rays emitted
are examined. In case of a normal sinus, the
pupil shows luminous glow and infra orbital
crescent of light is seen. In case of any
Fig. 13.2: Paranasal sinuses and their location
pathology no such light is emitted.
5. Bacteriological and cytological study of the
Functions of Maxillary Sinus
aspirates
1. Makes the cranium bone lighter in weight 6. Radiography: Intraoral and extraoral
2. Acts as a resonant bone radiographical techniques are used like
3. Regulates the temperature of the inspired air occlusal radiographs, water's projection,
4. Drainage tomography, MRI, ultrasound, scintigraphy.
5. Pneumatization
Classification of the Disorders STUDY OF SOME MAXILLARY

of Maxillary Sinus SINUS DISORDERS
1. Infection/Inflammatory:- Maxillary Sinusitis
i. Acute sinusitis
ii. Chronic sinusitis Inflammation of the mucous of the maxillary
2. Trauma sinus is called as maxillary sinusitis.
i. Oro-antral communication If all sinuses (maxillary, frontal, ethmoidal and
ii. Fracture of the maxillofacial skeleton sphenoidal) are involved, it is called as Pan
iii. Foreign bodies within the antrum sinusitis.
3. Cysts and tumors
4. Other bony abnormalities: Types
i. Fibrous dysplasia 1. Acute maxillary sinusitis: It is sudden in onset
ii. Paget's disease and persists for less than 4 weeks. Needs only
iii. Osteopetrosis short term therapy.
2. Subacute maxillary sinusitis: Features persists
Diagnosis of the Disorders for 4-12 weeks.
of Maxillary Sinus 3. Chronic maxillary sinusitis: Features persists
The diagnosis of the disorders is done by the for more than 12 weeks. May need surgical
combination of following methods: correction swell.
Maxillary Sinus and Its Disorders 173
Acute Maxillary Sinusitis 4. Fever, chill, fatigue, cough, sneezing

5. Fetid odour and halitosis due to fistulous
Etiopathogenesis: Viral conditions like influenza,
discharge
coryza, exanthematous fever, etc. effecting the
6. Tenderness on percussion over maxillary
upper respiratory tract leads to altering of the
tooth of involved area.
mucocillary function or sinus epithelium, which
predisposes it to secondary bacterial injections
Management
like Hemophilus influenza, Pneumococci,
Streptococcus pnemoniae. Proper diagnosis by combination of earlier
mentioned methods.
Antral regime should be followed, this
includes:
1. Nasal decongestants: 0.5 percent - 1 percent
ephedrine sulfate, in normal saline every 6th
hourly or 0.1 percent Xylometozolin
hydrochloride, can be used as nasal drops.
Tincture Benzoin or carvol, can be used as
inhalation.
2. Antibiotics: Procaine penicillin, Amoxicillin,
clavulanic acid or cephlosporine can be given
either by oral or parenteral route.
3. Mucolytics: Camphor, chlorbutal, menthol or
karrol capsules can be used to provide easy
Fig. 13.3: Sinusitis (For color version see plate 4) drainage of the mucous by making it into
a less viscous secretion.
Dental causes causing maxillary sinusitis:-
4. Analgesics: Paracetamol 500 mg - 750 mg
i. Oroantral communication
ii. Apical osteitis or other NSAIDs can be used to reduce
iii. Radicular cyst and residual cyst pains.
iv. Periodontal pockets An adjuvant of antihistamines like cetrizine
v. Impacted teeth and topical corticosteroids can also be used to
vi. Foreign body in sinus. give faster relief. Steam inhalation and hot
fermentation is also helpful.
Other causes
i. Nasal infection due to nasal obstruction Chronic Maxillary Sinusitis
ii. Nasal allergy
iii. Blowing nose strongly Etiopathogenesis
iv. Trauma (especially barotrauma)
v. Swimming and diving in infected water The normal mucosal cilliary tissues become
hypertrophic (polypoidal) or atrophic (sclerosed)
Clinical Features due to prolonged neglected dental infection or
other focus of infection.
1. Continuous nagging pain over antral cavity
and headache
Clinical Features
2. Facial pain and swelling
3. Nasal blockage with continuous purulent May be asymptomatic or with mild symptoms
unilateral nasal discharge of fever, tiredness, facial pain, headache, nasal
obstruction with prolonged mucopurulant Indications

discharge which does not subside despite
1. Retrieval of root or tooth from sinus
antibiotic therapy.
2. Enucleation of odontogenic cyst from sinus
3. Removal of odontogenic tumors from sinus
Complication
4. Treatment of chronic maxillary sinusitis
Infection of eyelid 5. Management of oroantral fistula
Orbital abscess 6. Repair of fracture of orbital floor or zygoma
Restricted eye movement and vision affected 7. Management of hematomas of the sinus with
Osteomyelitis of bone active bleeding through the nose.
Intracranial complications like meningitis,
encephalitis, extradural abscess and Procedures
cavernous sinus thrombosis
1. Mostly done under general anesthesia after
Descending infection like otitis media,
proper preoperative dental corrections are
pharyngitis, tonsillitis, laryngitis and
done.
tracheobronchitis
2. An intraoral incision of 2.5 cm is made along
the mucogingival sulcus in the canine fossa,
Management
lateral to upper canine and above the first
After proper diagnosis an adjuvant pharma- premolar (Fig. 13.4).
cologic regime is recommended as in case of 3. A hole is made at the centre of the canine
acute sinusitis to reduce the symptoms. fossa of the size of index finger using a bone
The focus of infection - either long standing gauge and ronguer (Figs 13.5 and 13.6).
dental infection, foreign body in sinus or oro- 4. Blood and pus is drained from the sinus,
antral fistula should be treated. foreign bodies are removed and only the
The purulent content should be properly diseased mucosa is removed by antral curette.
drained, either by irrigating in with antiseptic 5. Cavity is cleaned and soft tissues flap is
saline solution or by surgical drainage - using replaced and sutured over the bone.
Caldwall Luc technique or nasal antrostomy or 6. Nasal decongestants are recommended
functional endoscopic sinus surgery(FESS) preoperative and postoperative to shrink the
mucous membrane, thereby preventing
Nasal Antrostomy development of gross edema.
In this procedure a nasal antral window is made
using nasal rasp under the inferior meatus for
establishing a more dependent drainage. This
is done in conditions where natural ostium is
obstructed due to inflammation. Use of
mucolytics further facilitates sinus drainage.
After this antral packing with iodoform gauge
for 4-7 days is done.
Caldwell-Luc Operation
It is a procedure of reaching the maxillary sinus
via intraoral approach for various reasons. Fig. 13.4: Caldwell-luc operation incision line
Etiology
1. Pushing of tooth or root into the sinus while
extracting it (most common)
2. Periapical abscess, leading to destruction of
bony floor of sinus
3. Improper use of instruments leading to
damage of sinus floor.
4. Trauma to face
5. Surgical removal of cysts, polyp or tumor of
maxillary sinus
Fig. 13.5: Bone of maxillary sinus exposed 6. Osteomyelitis of sinus
7. Infected maxillary implant denture
8. Malignant diseases
Clinical Features
1. Symptoms:
i. Nasal discharge from posterior region of
nasopharynx into the mouth, leading to
fowl taste.
ii. Epistaxis (unilateral bleeding from nose)
iii. Change in voice due to enhanced column
of air
iv. Pain in the region
Fig. 13.6: Maxillary sinus reached v. Popping out of an antral polyp in chronic
cases
2. Signs:
Postoperative Complications i. Tenderness over maxilla
ii. Edema over cheek and infraorbital region.
1. Recurrent sinusitis
iii. Otitis media (middle ear injection)
2. Protracted numbness of lips, cheek and
iv. Fowl odour and halitosis
gingival
v. Nasal congestion
3. Oroantral fistula
4. Persistent cheek swelling.
Diagnosis
Foreign Bodies within the Antrum Part of bony floor of sinus seen along with
extracted tooth apex
The details of the causes, diagnosis and
Close nose and blow inward, bubbling of air
management of this has been described under
in the oral opening of fistula or the blowing
complications of exodontia.
of cotton kept in the area is seen
Radiographic evaluation
Oro-antral Communications
Rhinoscopy
(Oro-antral Fistula)
Never probe or irrigate the area or blow
It is an unnatural communication between the nose, as it can lead to confirmation of fistula
oral cavity and maxillary sinus. opening and spread of injection in the area.
Treatment 3. If patient comes after gingival has healed

(chronic fistula) then surgical closure of the
The treatment of oro-antral fistula aims at:
opening along with Caldwell Luc operation
1. Protect sinus from microorganism
to retrieve root piece or to drain out the pus
2. Prevent escaped of fluid via communication
is done. The surgical closure can be done
3. Establish drainage via inferior meatus
by advancing either buccal flap or palatal flap
4. Eliminate existing pathology of sinus
by combination of buccal and palatal flap.
Treatment of early cases (Iatrogenic opening)
i. Buccal flap advancement procedure (Von
(where fistula has not formed and only
Rehrmann flap): After excising the whole
communication has occurred): Immediate
fistulous tract along with some soft tissue
primary closure by sliding buccal flap and
margin (Fig. 13.8), a trapezoidal buccal flap
acquiring enough soft tissues to cover the whole
is reflected to close the whole opening (Fig.
opening (Fig. 13.7). Supportive treatment of
13.9). Sutures are placed over firm bone
decongestants, mucolytics, antibiotics and
and post operative care are taken (Fig.
analgesics is recommended.
13.10).
Fig. 13.7: Sliding buccal flap

Treatment measures to prolong surgical
closure, especially when root piece has to be Fig. 13.8: Excision of fistula
retrieved at a later date:-
This is done by following ways:
1. Gauge packed in medicaments like white
head varnish is sutured and held in the
position till surgery.
2. Acrylic stent is placed in position till surgery.
Treatment of delayed cases (chronic fistula):
1. If patient comes within 24 hours then the
edge is cleaned and primary closure is
achieved by sliding buccal flap technique.
2. If patient comes after 24 hours then
postpone the treatment for 3-4 weeks until
the gingiva has healed and fit for surgical Fig. 13.9: Buccal Fig. 13.10: Buccal
procedure. flap reflected flap sutured
ii. Palatal flap advancement procedure: After iii. Metallic - foil closure of oroantral communi-
excising the whole fistulous tract along with cation: Both facial and palatal muco-
same soft tissue margin, a palatal flap of periosteal flaps are reflected and the whole
enough length and containing the anterior fistulous tract along with its margins are
palatine artery for providing adequate blood excised (Fig. 13.14). A metallic - foil "Patch"
supply is reflected (Fig. 13.11). This flap is (usually gold foil) is adapted to cover the
then rotated and sutured over firm bone whole defect and positioned between
to cover the whole opening (Fig. 13.12). alveolar process and overlying buccal and
Iodoform gauge is placed over the raw palatal mucoperiosteal flaps. The
healing palate and proper post operative mucoperiosteal flap is then repositioned
care is taken (Fig. 13.13). and sutured over the foil (Fig. 13.15).
Fig. 13.11: Incision of flap Fig. 13.14
Fig. 13.12: Reflection of flap
Fig. 13.15
Functional Endoscopic
Sinus Surgery (FESS)
It is a minimally invasive technique where the
sinus air cells and sinus ostia are opened under
direct visualization to restore the normal
Fig. 13.13: Flap sutured functions of the paranasal air sinuses with
mucocilliary activity. This procedure aims in 5. CSF leak closure

identifying and correcting the primary cause of 6. Orbital decompression
the disease, secondary disease in sinus will often 7. Optic nerve decompression
improve spontaneously. 8. Foreign body removal
Advantages over conventional sinus surgery:- 9. Epistaxis control
1. Surgery is less extensive 10. Orbital abscess and cellulitis.
2. Less removal of normal tissues
3. Surgery can be performed on an outpatient FURTHER READING
basis without the need for nasal packing. 1. Anon, Rontal, Zinreich Anatomy of paranasal
4. Better visualization is obtained during surgery sinuses.
by the use of endoscopes. 2. Archer WH Oral and maxillofacial surgery 5th
Indications for FESS: ed, Vol. 2.
3. Gustov O Kruger Textbook of oral and
1. Chronic sinusitis maxillofacial surgery, 6th ed.
2. Nasal polyposis 4. Peterson, Ellis, Hupp, Tucker Contemporary
3. Sinus mucoceles oral and maxillofacial surgery, 4th ed, 2006.
4. Excision of selected tumors 5. Stranding Grays anatomy, 39th ed.
Cysts of the
Oral Cavity
14
A cyst is a pathological cavity or sac with the hard or soft tissue. Lined by epithelial or non epithelial
tissue and containing fluid, semi fluid or gaseous content.
CLASSIFICATION OF OROFACIAL CYSTS
A. By Shear and Kramer

1. Cyst of jaw 2. Cyst of maxillary antrum 3. Cyst of soft tissue
i. Benign mucosal cyst i. Dermoid cyst
ii. Surgical ciliated cyst ii. Epidermoid cyst.
iii. Benign lymphatic cyst
i. Epithelial ii. Nonepithelial iv. Salivary gland cyst
a. Traumatic bone cyst (mucocele)
(hemorrhagic cyst) v. Thyroglossal duct cyst
b. Aneurysmal bone cyst vi. Parasitic cyst
(ABC) vii. Anterior lingual cyst
a. Developmental b. Inflammatory (odontogenic)

Radicular cyst
Residual cyst
Odontogenic Nonodontogenic
- Primodial (keratocyst) - Nasopalatine cyst (Incisive canal cyst)
- Dentigerous cyst - Nasolabial cyst (Nasoalveolar cyst)
- Eruption cyst - Median alveolar cyst.
- Lateral periodontal cyst - Median palatal cyst
- Gingival cyst - Median mandibular cyst
- Calcified odontogenic cyst or - Globulo-maxillary cyst.
Gorlins cyst
- Basal cell nevus syndrome
- Botryoid odontogenic cyst.
B. By Harris and Seward PATHOGENESIS OF

1. Odontogenic epithelial cysts:-
CYST FORMATION
I. Derived from dental lamina. There are mainly two stages in cyst formation:-
i. Kertocysts. 1. Initiation: There are various initiating cells like
a. Solitary or primordial cyst dental lamina, epithelial rest of Malassez,
b. Pseudofollicular or extrafollicular reduced enamel epithelium or bony tissues
dentigenous cyst. which initiates the cystic cavity formation.
ii. Calcified odontogenic cyst (Gorlin's 2. Enlargement: A cystic lesion expands in a
cyst) balloon-like manner resorbing the surround-
II. Derived from reduced enamel epithelium ing bone, the expansile force being created
i. Eruption cyst by an accumulation of intra cystic content
ii. Follicular or Dentigerous cyst which is:
a. Pericoronal i. Cyst epithelium and its products of autolysis
b. Lateral ii. Plasma proteins derived from transudation,
c. Residual exudation and intracystic hemorrhage.
III. Derived from epithelial rest of Malssez
iii. Tissue fluids drawn into the cyst owing to
i. Inflammatory periodontal (Radicular)
the high osmolality created by (i) and (ii).
a. Apical
iv. Mucous secreted by the Goblet cells, which
b. Lateral
are formed in some follicular, and
c. Residual
nasopalatine cyst wall.
2. Non-odontogenic epithelial cyst (fissural)
I. Nasopalatine cyst
II. Nasolabial cyst
DIAGNOSIS OF OROFACIAL CYSTS
3. Bone cysts - (cyst without epithelial lining) The diagnosis of a cyst is done by the combination
I. Solitary bone cyst of following methods:
II. Aneurysmal bone cyst History taking and clinical diagnosis.
DIAGNOSIS BY ASPIRATION
No. Name of Pathology Aspirate's Physical Features Aspiration Other Features
1 Dentigenous cyst - Clear pale, straw coloured fluid - Cholesterol crystals.
- Total protein exceeds 4.0 gm per 100 ml.
2 Odontogenic keratocyst - Dirty, creamy white viscous suspension - Parakeratinised squamous
(OKC) - Total protein is less than 5.0 gm per 100 ml.
3 Periodontal cyst - Clear, pale yellow strew coloured fluid - Varying amount of cholesterol crystals.
- Total protein content is between 5 gm
and 11 gm per 100 ml.
4 Infected cyst - Pus or brownish fluid, seropurulent/ - PMN leukocytes
sanguine purulent fluid, at times - Foam cells
paste like or caseous consistency. - Cholesterol clefts.
5 Mucocele, Ranula - Mucus
6 Gingival cysts - Clear fluid
7 Solitary bone cyst - Serous or sanguineous fluid, blood - Necrotic blood clot.
or empty cavity.
8 Stafne's bone cyst - Empty cavity, will yield air.
9 Dermoid cyst - Thick sebaceous material.
10 Fissural cyst - Mucoid fluid
11 Vascular cyst walls - Fresh blood.
Cysts of the Oral Cavity 181
Radiographic diagnosis to differentiate mucosa and then evacuating all of the cystic
unilocclular or multilocclular cysts lined by contents (Fig. 14.1).
radioopaque border of sclerotic bone.
Histopathological diagnosis by biopsy Indications
procedures.
In case of large cysts located in inaccessible
Laboratory diagnosis.
areas.
TREATMENT OF AN In large cyst with weakened cystic wall
OROFACIAL CYST For dentigerous cyst in young patient were
teeth eruption is necessary.
A cyst is mostly treated by surgical method as
In patients where complicated surgeries are
these lesions increase in size, destroys
contraindicated.
surrounding bone, weakens the jaw ultimately
leading to pathological fracture, involve erupted
or unerupted teeth or encroach upon important
Advantages
vital neighboring structures. Despite all these It is a simpler and easy procedure.
complications in certain cases surgical treatment It spares the vital structures
is not preferred. These conditions are - small This procedure also allow the teeth to erupt.
asymptomatic cysts or patients with complicated It requires less time.
systemic illness. There is less blood loss in this procedure.
The objectives of the treatment of a cyst are:- It is a conservative method as it preserves
1. Removal of the cyst lining or a devise to bone height.
position the abnormal tissue to ensure its
elimination from the site. Disadvantages
2. Preservation and respect to the adjoining
important structures. In this procedure, the pathological tissues are
3. Conservation of healthy teeth either erupted not completely removed.
or unerupted. It takes increased healing time.
4. Restoration of the affected area to its normal/ It requires prolonged follow up
original formula, shape as far as possible. There is greater chance of recurrence.
The various surgical procedures are:-
1. Marsupialization or decompression technique
(Partsch I)
2. Enucleation technique:
- Enucleation with primary closure.
- Enucleation with packing
- Enucleation with primary closure and
reconstruction (graft surgery)
3. Combination of enucleation and marsupiali-
zation (Partsch II).
1. Marsupialization or
Decompression Technique
It is a procedure of surgically creating a window
in the cyst wall which is continuous with the Fig. 14.1: Marsupialization
Procedure and the space fills with blood clot which is

covered by the flap reflected (Fig. 14.3).
The steps involved for malsupialization of a cyst
are:
Administration of anesthesia Indication
The cyst is aspirated For management of odontogenic keratocysts.
An inverted V-shaped incision made around In case of recurrent cysts.
the cyst. In small cysts
The flap is reflected and the bone underlying
is revealed. Advantages
The bone is removed along with periosteum
and the cyst lining. Healing is rapid if primary closure is attained.
Irrigation of the wound is done. In this procedure, the complete cystic lining
Suturing of the cyst lining to the edge of the can be examined.
oral mucosa is done. Post-operative care is less.
Pack the cystic cavity with gauge dipped in
antibiotic ointment, iodoform, eugenol and Disadvantages
white head varnish. In this case, the teeth have to be generally
Plugging of the cavity is done. removed.
Patient should be recalled for routine and
This procedure, cannot be done if cyst is near
regular follow up.
vital structure like sinus or nerve bundles.
This procedure weakens mandible and
2. Enucleation
makes it prone to fracture.
It is a process of surgically removing a complete
cyst, tumor or an organ (Fig. 14.2).
Fig. 14.2: Enucleation
Enucleation with primary closure: It is the

complete removal of cyst with its epithelium lining Fig. 14.3: Enucleation with primary closure
Procedure is case of large cyst removal using stainless steel

or titanium reconstruction plates. Here
The steps performed during primary closure are:
autogenous bone grafts (iliac crest or rib) can
Anesthesia administered.
be used which is immobilized by intermaxillary
Incision is placed parallel to the cyst on hard
ligation and fixation.
bony structure either intraorally or extraorally.
Reflection of mucoperiosteal flap is done.
3. Combination of Enucleation and
If required, then the overlying bone is
Marsupialization (Partsch II)
removed.
Then the cyst is separated from the attached This procedure is performed in case of large cyst
structures. removal. It is a Z stage procedure. It involves:
Complete retrieving of the cyst is done. Stage Imarsupialization, to allow shrinkage
Irrigation of the wound is done. of cyst.
Suture the flap back. Stage IIenucleation to remove the reduced
cyst completely.
Enucleation with packing: The procedure of this
technique is similar to that of primary closure COMPLICATION OF TREAMENT
and is indicated in conditions where large cyst
removal is to be done and clot stabilization is They are:
difficult. Iodoform gauge or other antimicrobial 1. Edema and swelling
packing is given which is regularly changed until 2. Infection
the lesion shrinks, followed by primary closure 3. Hematoma
(Fig. 14.4). 4. Neural injuries
5. Tooth being non-vital.
Enucleation with primary closure and 6. Oro antral and oro nasal fistula.
reconstruction surgery: This procedure is done 7. Pathological fracture.
8. Recurrence of cyst.
9. Malignant transformations.
In some case a more conservative approach
is used, mainly to prolong the surgical procedure.
This is chemical cauterization. For this the
chemical solutions used are:
1. Carnoy's solution:-
60 ml absolute alcohol
+
30 ml chloroform
+
10 ml acetic acid.
2. Phenol brushing followed by rinsing with
95 percent ethanol and saline.
Chemical cauterization is also used after the
Fig. 14.4: Enucleation with packing surgical process to prevent recurrence.
STUDY OF SOME COMMON OROFACIAL CYSTS
No. Name Pathogenesis Clinical features Radiographic features Treatment
1. Odontogenic Stellate reticulum in -Mostly seen in young A well defined -Enucleation along with
keratocyst (OKC) the enamel organ adult males. multiloccluar curratage is done.
or Primodial cyst. disintegrates to form -Mandibular 3rd molar radiolucent area marsupilization is not
a cystic cavity lined and supernumery tooth bounded by smooth done.
by inner and outer are most involved. cortical bone. -Block dissection with or
enamel epithelium - Rarely any other without graft can also
cells. fractures seen except be done for large cysts.
missing of tooth - Best method is to
involved. enucleate the cyst
followed by excision
of normal overlying
mucosa or muscle
and then chemical
cauterization to
prevent high
recurrence.
2. Dentigerous cyst Cystic proliferation of -Seen in any age and 3 varieties are there - Marsupialization is
the cells between the mostly in impacted central, lateral and done in case of large
dental crown of the mandibular 3rd molar. circumferential. cyst present in
involved impacted tooth -Expansion and children where tooth
and reduced enamel destruction of cortical eruption is to be
epithelium covering it bone leading to facial achieved, otherwise
leads to formation of asymmetry. enucleation and
cyst. extraction of involved
tooth is done.
Treatment aims at
removal of cyst along
with eruption of tooth
involved, prevention
of recurrence,
prevention of
amyloblastoma
formation and
symptomatic relief.
3. Mucocele Two different -Dome shaped, --------------- -Marsupialization and

pathogenesis are there- circumscribed, bluish enucleation is not
mucous extravasation translucent swelling affective as recurrence
due to trauma and mostly in the lower lip. is common. Thus,
mucous retardation due -Pain while swallowing complete removal of
to obstruction in -Xerostomia gland is
salivary gland. -In rare, deeper lesions recommended.
there may be no signs
seen.
Contd...
Contd...
No. Name Pathogenesis Clinical features Radiographic features Treatment
4. Ranula Mucous extravasation -Similar to mucocele -------------- -Surgical removal of

type of cyst is there but seen in complete sublingual
submandibular region gland.
only.
5. Aneurysmal bone A cystic cavity is formed -Seen at all ages. -Honeycomb or soap -Surgical curettage or
cyst (ABC) mainly due to trauma, -Firm swelling which bubble appearance is excision of the lesion.
venous occlusion or rapidly enlarges due to seen.
hemdynamic disorders continued bleeding.
-Tender, painful and
displaced tooth.
6. Nasolabial cyst Raminants of -Unilateral, often ---------- -Surgical removal of the

(Kledstat cyst) nasolacrimal duct painless swelling is seen lesion.
develop into cysts on the lip.
swelling.
FURTHER READING 5. RA Cawson Essentials of dental surgery and

pathology, 5th ed.
1. Dr Ramjit Sen Surgery for oral and 6. Shafer-Hine-Levy Shefers Textbook of oral
maxillofacial cysts and tumours. pathology, 5th ed, 2006.
2. Greenberg and Glick Burkets oral medicine, 7. Topazian RG, Goldberg MG Oral and
diagnosis and treatment, 10th ed. maxillofacial infections, 3rd ed, 1994.
3. Mervyn Shear and Paul M Speight Cysts or oral 8. Waite DE Textbook of practical oral and
and maxillofacial regions, 4th ed. maxillofacial surgery, 3rd ed, 1987.
4. Omar Abuboker, Keneth Benson Oral and
maxillofacial surgery secrets, 2nd ed.
Tumors of the
Oral Cavity and 15
Oral Malignancies
According to Willis a tumor or neoplasm is an CLASSIFICATION OF

abnormal mass of tissue, the growth of which NONODONTOGENIC TUMORS
exceeds and is uncoordinated with that of the
normal tissue and persists in the same excessive 1. Nonodontogenic tumors:
manner after cessation of the stimuli which evoke i. Central fibroma.
the change. ii. Myxofibroma.
iii. Ossifying fibroma.
CLASSIFICATION OF iv. Osteoma.
ODONTOGENIC TUMORS v. Osteoid osteoma
1. Tumors from epithelial origin: vi. Benign osteoblastoma
i. Enameloma. vii. Chondroma
ii. Ameloblastoma. viii. Giant cell granuloma
iii. Adenomatoid odontogenic tumour (AOT) ix. Central hemogioma
iv. Calcified epithelial odontogenic tumor x. Benign tumor of nerve tissue.
(CEOT) or Pindborg's tumor. 2. Fibro-osseous lesion:
2. Tumors from mesenchymal origin: i. Fibrous dysplasia of bone
i. Odontogenic fibroma. ii. Cherubism
iii. Ossifying fibroma.
ii. Odontogenic fibrosarcoma.
iv. Central giant cell granuloma.
iii. Odontogenic myxoma
iv. Periapical cemental dysplasia (cementoma)
v. Central camentyfying fibroma. DIAGNOSIS OF OROFACIAL TUMORS
vi. Dentinoma The diagnosis of a tumor is done by the combi-
3. Tumors from mixed origin: nation of following methods.
i. Ameloblastic fibroma. History taking and clinical diagnosis.
ii. Ameloblastic fibrosarcoma. Radiographic diagnosis to differentiate
iii. Ameloblastic fibroodontoma uniloccular or multioccular radiolucent and
iv. Odontoma. radio opaque lesions.
v. Ameloblastic odontoma Histopathological diagnosis by biopsy
vi. Teratoma. procedures.
Tumors of the Oral Cavity and Oral Malignancies 187
TREATMENT OF OROFACIAL
TUMORS
A conservative approach of curettage with
chemical cauterization is followed in some cases
but mostly a more severe surgical approach is
to be done. These surgical approaches are:
1. Enucleation with or without curettage.
2. Marsupialization or Partsch operation.
3. Resection without continuity defect also
known as marginal resection (EN Block
resection) (Fig. 15.1).
4. Resection with continuity defect (the Fig. 15.1: Resection without continuity defect
operation for extensive lesions include the (En block resection Marginal ressection)
inferior border of the mandible)
5. Partial resection or peripheral ostectomy.
6. Hemimandibulectomy with removal of
condylar head (disarticulation) (Fig. 15.2).
7. The CO2 laser and cryotherapy has been
reported in the management of ameloblas-
toma in small lesion.
The treatment choice for the treatment of
orofacial tumors depends on the fact that it
should fulfill these goals:
1. Complete removable of lesion
2. Preservation of normal tissues
3. Restoring tissue anatomy and function.
4. Long term follow up and prevent recurrence. Fig. 15.2: Resection with continuity defect
STUDY OF SOME COMMON OROFACIAL TUMORS

Sl.No. Name of tumor Clinical features Radiographic features Histological features Treatment
1. Ameloblastoma - Seen mostly in -Mostly diagnosed by -7 Histological -Conservative

middle aged people radiographic fractures. variations treatment of
and involves mostly -Uniloccular or i. Follicular curettage and
mandibular molar, muttiloccular ii. Plexiform cauterization is
ramus area. radiolucent area with iii. Cystic ineffective because
- Generally asympto- scalloped sclerotic bone iv. Basal cell of high recurrence
matic but rarely outline. Shows a 'soap v. Desmoplastic rate.
shows jaw expansion, bubble' or 'honeycomb' vi. Granular, and -Marginal or partial
tooth mobility and appearance. vii. Acanthomatous. resectioning with or
malocclusion. without
- May be intraosseous reconstruction is
extraosseous or recommended.
extraoral - pituitary
ameloblastoma.
Contd...
Contd...
Sl.No. Name of tumour Clinical features Radiographic features Histological features Treatment
2. Central epithelial -Mostly seen in -multiloccular or -Polyhedral cells - Marginal or

odontogenic middle ages people uniloccular radiolucent arranged in sheaths partial resectioning
tumor (CEOT) or and involves mostly area with scalloped with multinucleated with or without
Pindborg's tumor. mandibular 3rd molar sclerotic bone outline and giant cells, clear cells reconstruction is
and premolar containing flecks of and Leisgang bodies recommened.
- Generally calcifications shows 'snow are seen.
asymptomatic but driven appearance'.
rarely shows painless
expansion of bone.
3. Cementoma -Mostly seen in people -Well defined solitary -Sheaths of cemental -Enucleation and or
4 types: below 25 years and vital radio opaque lesion like tissues resembling curettage with or
i. Benign cemento- mandibular 1st molar is with surrounding secondary cellular without removal of
blastoma. (True most involved. radiolucent border and cementum and involved tooth.
cementoma) - Slow growing expan- is attached to the root of having reversal line,
sion of cortical bone the involved tooth. vascular and cellular
and root resorption. elements.
ii. Periapical -Mostly seen in middle -Initially in the osteolytic -Sheats of cemental -Enucleation and/or
cemental dysplasia aged females and stage it is a radiolucent like tissues resembling curettage with or
involves mostly lesions. secondary cellular without removal of
mandibular incisions. -Then radio opaque cementum is seen. As tooth.
-Mostly asymptomatic spicules are seen on the the stage increases,
but rarely may show radiolucent surface calcified spicules are
expansion of bone. cementoblastic stage. seen.
-Finally is the maturitive
stage it is completely
radio opaque.
iii. Gigantiform
cementoma
iv. Other cemental
lesions.
4. Odontoma 3 types: -Irregular, simple, -Shapeless, small, radio -Calcified mass with -Enucleation and/or
i. Complex calcified dental mass opaque mass with ghost cells is seen. curettage may be
cementoma. with no morphological radiolucent border. needed for prosthetic
bearing to a tooth is reasons or else no
seen or abnormal treatment is needed if
position. asymptomatic.
-Swelling, asymmetry
and infection of jaw
may be there otherwise
mostly asymptomatic
Contd...
Contd...
Sl.No. Name of tumour Clinical features Radiographic features Histological features Treatment
ii. compound -Structure similar to a -Variable number of -Normal appearing - Same as complex
cementoma natural tooth is seen on tooth like structure is enamel, dentine, pulp cementum.
abnormal position, seen. and cemetum is seen.
mostly on posterior
tooth.
- mostly asymptomatic
iii. Compound -Combination of (i) -Combination of (i) and -Combination of (i) - Same as complex
complex and (ii). (ii). and (ii). cementum.
cementoma.
5. Myxoma. -Mostly seen in -Uniloccular or -Gelatinous texture -Marginal or partial

middle aged people multiloccular mixed radio with shiny appearance resectioning with or
and involves mostly opaque and radiolucent is seen. without
mandibular tooth. lesion with well defined reconstruction is
-mostly asymptomatic smooth or scalloped recommended.
but sometimes may margin shows a
show hard slow 'Honeycomb' or 'soap
growing swelling as bubble' appearance.
facial assymmetry.
6. Fibrous dysplasia -Mostly seen in children -Initially in the early stage - Proliferating -Enucleation and/or
of bone 2 types: and involves mainly unilocular or multilocular fibroblast in a curettage is done, if
i. Mono-osteotic maxillary jaw. radiolucent lesion is seen. compact stroma of needed with or
type. -Asymptomatic slow -Then multilocular, interlacing collagen without
growing lesion and mixed radio opaque fibres and irregular reconstruction.
involving only one and radiolucent lesion bony trabeculae is
bone. Sometimes facial involving the seen. Shows
asymmetry may be surrounding structure "Chinese letter like"
seen. -mixed stage "mottled appearance.
appearance".
ii. Poly-osteotic -Asymptomatic slow -Finally at the mature

type. growing lesion and stage, a dense
involving more than radioopaque lesion is
one bone. Caf-au-lait seen-shows "peau de
pigmentation on skin is orange" or "ground
seen. glass" or "orange peel"
appearance.
ORAL MALIGNANCIES and is thus generally aminable to local surgical

removal and better survival of the patient.
Definitions 2. Malignant: A Tumor is said to be malignant
1. Benign: A Tumor is said to be benign when when the adjacent structures are involved
its microscopic and growth characteristics will and spread to distal site (metastasis) to finally
remain localized, cannot spread to other sites cause death.
3. Precancerous lesion: It is a morphologically Giant cell tumor

altered tissue in which cancer is more likely Metastatic tumor
to occur than in apparently normal
counterpart. ETIOLOGY OF ORAL MALIGNANCIES
Examples: Erythroplakia, leukoplakia, palatal
Factors that promote development of cancer
changes seen in reverse smoking.
are:
4. Precancerous condition: It is a generalized
1. Increasing age.
state associated with a significantly increased
2. Immune deficiency
risk for cancer.
3. U.V Radiations
Examples: Oral submucous fibrosis, syphilis
4. Tobacco and alcohol
and oral hairy leukoplakia.
5. Diet and nutritional deficiency
CLASSIFICATION OF ORAL 6. Fungal infection
MALIGNANCIES 7. Viruses
8. Oro dental irritations.
1. Odontogenic hard tissue tumors: The 6 'S' of cancer etiology:
i. Odontogenic carcinomas: 1. Syphilis
Malignant ameloblastoma. 2. Spices
Primary intra osseous carcinoma 3. Smoking
Malignant variant of other odontogenic 4. Sepsis
epithelial tumors like malignant CEOT. 5. Sharp tooth
Malignant neoplasm arising from 6. Spirit
odontogenic cysts.
ii. Odontogenic sarcomas: GENERAL FEATURES OF
Ameloblastic fibrosarcoma. ORAL MALIGNANCIES
Ameloblastic fibro odontosarcoma.
2. Non odontogenic soft tissue tumors: They are initially asymptomatic and are
i. Malignant epithelial neoplasm: mostly identified after development of
Carcinoma in sites symptoms and after progression of disease.
Squamous cell carcinoma Patient discomfort is the most common
Basal cell carcinoma symptom.
Verrucous carcinoma Lesion may appear as a diffuse swelling or
Melanoma ulcerated mass or swelling.
Metastatic carcinoma. Patient complains of dysphasia, odynophagia
ii. Malignant connective tissue neoplasm (pain in tongue while swallowing), otolgia,
Fibrosarcoma limited movement of mandible and oral
Malignant fibrous histocytoma. bleeding.
Liposarcoma Tissue change that may occur includes red,
Rhabdomyosarcoma white or mixed red and white lesions.
Leiomyosarcoma Lesion may be flat or elevated, ulcerated or
Lymphomas non ulcerated, palpable or non palpable.
Kaposi's sarcoma. Loss of function involving tongue may affect
3. Neoplastic lesions of jaw and facial bone. speech, swallowing and diet.
i. Malignant neoplasm Quantalateral and bilateral lymph nodes
Orthosarcoma become enlarged, firm to hard in texture,
Chondrosarcoma non tender unless associated with infection
or an inflammatory response present Grade II Moderately differentiated 25 - 50

following biopsy and fixed to adjacent tissues. percent anaplastic cells.
Grade III Moderately differentiated, 50 - 75
GRADING AND STAGING percent anaplastic cells.
OF ORAL MALIGNANCIES Grade IV Poorly differentiated, more than
75 percent anaplastic cells.
Broader's Grading of Squamous
Cell Carcinoma TNM Staging of Oral Malignancies
Grade I Well differentiated, less than 25 T Is determined by size of primary tumor.
percent anaplastic cells. N Presence of lymph node involvement.
M Distant metastasis.
Sl.No. T N M Staging
1. T1s - Carcinoma in situ 1. N0 - No node involvement. 1. M0 - No node Stage 1
metastasis. T1 N0 M0
2. T1 - tumor less than 2 cm. 2. N1 - Single ipsilateral 2. M1 - metasis present. Stage 2
less than 3 cm. T2 N0 M0
3. T2 - tumor more than 3. N2 -
2 cm less than 4 cm. a. Single ipsilateral Stage 3
more than 3 cm and less T3 N0 M0 or
than 6 cm. Any T N1 M0
4. T3 - tumor more b. Multiple ipsilateral less Stage 4
than 4 cm. than 6 cm. T4 any N M0
5. T4 - tumor more c. Bilateral or contralateral any T N2/N3 M0 or
than 4 cm less than 6 cm. any T any N M1
with invasion of adjacent 4. N3 -
structure, i.e. through the a. ipsilateral more than 6 cm.
cortical bone deep into the b. Bilateral more than 6 cm.
muscle, tongue, sinus and skin.
DIAGNOSIS OF ORAL 1. Site of lesion.

MALIGNANCIES 2. Lymph node status.
3. Presence of bone and adjacent structures
Diagnosis of oral malignancies is done by the involvement
combination of following methods: 4. Ability to achieve adequate surgical margin.
1. Proper clinical examination 5. Ability to preserve speech and swallowing
2. Toluidine blue staining and Acridine binding functions
method. 6. Physical and mental status of the patient
3. Histopathological diagnosis by biopsy 7. Through assessment of potential compli-
procedures
cations of the treatment made.
4. Imaging techniques.
8. Experience of surgeon and radiotherapist.
9. Personal preference and co-operation of
TREATMENT OF ORAL patient.
MALIGNANCIES
The treatment choices are:
The choice of treatment depends on the following 1. Surgical treatment (resection with or without
factors: reconstruction)
2. Radiation therapy iii. Estrogensdiethylstilbesterol

Brachytherapy iv. Antiestrogentamoxifen
External beam therapy v. Progestinshydroxyl progesterone
Radiation using heavy charged particles. vi. RH analogueleuprolide
3. Chemotherapy vii. Adrenal suppressantamino gluthetimide
4. Immunotherapy viii. Antiandrogensflutamide, nilutamide
5. Cryosurgery. 6. Radioactive isotopes-
I131, Au198, P32
Various chemotherapeutic agents are
7. Topoisomerase inhibitors-
(Antineoplastic drugs):
topotecan, irnotecan
1. Alkylating agents
8. Miscellaneous
i. Nitrogen mustardscyclophosphamide,
Hydroxyureas, interferons, asparginase.
chlorambucil
ii. NitrosureasTomustine, streptozotocin
FURTHER READING
2. Antimetabolites
i. Folate antagonistmethotrexate 1. Archer WH Oral and maxillofacial surgery, 5th
ii. Purine analogue6-meracaptopurine, ed, Vol. 2.
thioguanine 2. Burkhardt and Maerker Oral cancer.
3. Dr. Ranjit Sen Surgery for oral and maxillofacial
iii. Pyrimidine analogs5-fluorouracil
cysts and tumours.
3. Antibiotics 4. Greenberg and Glick Burkets oral medicine,
Dactinomycin, mitomycin, plicamycin, diagnosis and treatment, 10th ed.
rubidomycin 5. Jatin P Shah, Newell W Jhonson, John G Batsakis
4. Plant products Oral cancer.
i. Vinca alkaloidsvincristin, vinblastin 6. Myers Suen, Myers Hanna Cancer of the head
ii. Taxoidspaclitaxel and neck.
7. Norman K Wood, Paul W Goaz Differential
iii. Epipodophyllotoxinsetoposide
diagnosis of oral and maxillofacial lesions, 5th ed.
5. Hormones 8. RA Cawson Essentials of dental surgery and
i. Corticosteroidsprednisone pathology, 5th ed.
ii. Androgenstestolactone 9. Shafer-Hine-Levy-Shafers Textbook of oral
pathology, 5th ed, 2006.
Salivary Gland and
Its Disorders
16
Salivary glands are glands that produce saliva. runs for a short distance obliquely forward
There is three pair of major salivary glands between the buccinator and the mucous
parotid gland, submandibular gland and membrane of the mouth. Duct has a thick wall
sublingual gland; and few groups of minor which narrows at the opening into the mouth.
salivary glands. These glands are stimulated by
reflex action, which can be initiated by the taste, Submandibular Gland
sight or thought of food to secrete saliva.
It is a walnut- sized mixed salivary gland (which
secretes both mucous and serous fluid) is placed
ANATOMY OF MAJOR
in the submandibular triangle. It reaches
SALIVARY GLAND
anteriorly to the anterior belly of digastric and
Parotid Gland posteriorly to the stylomandibular ligament. The
gland extends superiorly under the inferior
It is the largest salivary gland and is placed at border of mandible. The upper part of superficial
the side of the face just below and in front of
surface of the gland lies partly against the
the external ear. The gland has two parts -
submandibular depression on the inner surface
superficial and deep.The main part of the gland
of mandible and partly on the medial pterygoid
is superficial, which is flattened and quadrilateral. muscle. The lower part is covered by skin,
It lies between the ramus of mandible, mastoid superficial fascia, platysma and deep cervical
process, temporal bone and sternocleidomastoid fascia.
muscle. It is wide superiorly and reaches up to The submandibular duct is known as the
the zygomatic arch while inferiorly it tapers near Wharton's duct, starts at the deep surface of the
the angle of mandible. The gland is enclosed gland and runs between the sublingual gland
in a capsule which is continuous with the deep and genioglossus. It opens on a small papilla at
cervical fascia. the side of lingual frenum.
The parotid duct which is known as the
Stenson's duct starts at the anterior border of Sublingual Gland
the gland and opens in the vestibule of mouth
opposite the crown of upper second molar tooth. It is a paired salivary gland which is situated under
It is 7 cm long and while leaving the parotid the mucous membrane of the floor of the
gland it lies over the masseter, pierces buccinator, mouth, beneath the tongue. It is narrow and
almond shaped. The alveoli of sublingual gland 4. Water balance: Maintains appropriate level
secrete mucus. It is bounded inferiorly by the of hydration
mylogyoid, posteriorly by submandibular gland, 5. Hormonal function: Epidermal growth factor
laterally by mandible and medially by the and other polypeptide hormones are found
genioglossus from which it is separated by the in the saliva.
lingual nerve and submandibular duct. The
sublingual duct is called as the Bartholin's duct DIAGNOSIS OF SALIVARY
and opens in the floor of the mouth. Minor GLAND DISORDERS
sublingual duct is called as duct of Rivinus. The diagnosis of salivary gland disorder is done
by the combination of following methods.
1. Proper case history and clinical evaluation
2. Study of flow rate from major salivary gland
3. Salivary gland scanning (scintigraphy)
The salivary gland takes up compound of
periodic group VII elements such as iodine,
bromine and technetium and thus is used
for studying the glandular parenchyma.
4. Ultrasonography
5. Computerized tomography
6. Arteriography to study the vasculature
tumor.
7. Histopathological study by biopsy
procedure
Fig. 16.1: Location and position of major
8. Magnetic resonance imaging
salivary glands and their ducts 9. Laboratory analysis of the content of the
saliva
10. Sialography
FUNCTIONS OF SALIVA
It is a specialized radiographic technique used
(SECRETION OF SALIVARY GLAND)
to diagnose various salivary gland disorders.
1. Digestive function: Helps in formation of food Indications for sialography-
bolus and action of enzyme amylase and i. To study normal anatomy and physiology
lipase of gland.
2. Protective function: ii. To detect any obstructions and shrinkage
Lubricating and keeps the oral tissues of duct.
moist. iii. To detect chronic inflammatory condition
Cleansing and buffering action which of the gland
protects teeth from dental caries. iv. To detect stones and tumor or foreign body
Dilates hot or irritating substances and of gland.
thus prevents injury to mucus membrane. v. To detect fistula of gland
Antibacterial properties. vi. Selection of biopsy site.
Accelerates wound healing by the Contraindications for sialography
presence of nerve growth factor and a. Acute infections of gland
epidermal growth factor. b. Patients with known sensitivity to iodine
3. Excretory function: Many drugs as well as containing compounds.
alcohol are excreted into saliva. c. Patients anticipated for thyroid function test.
Salivary Gland and Its Disorders 195
Technique for Sialography 5. In sialolithiasis, a cigar shaped or oval shaped

radio opacity is seen.
It is a close system cyanographic technique where
6. In benign tumor of gland, a ball in hand
a lacrimal probe is used to dilate the sphincter
appearance is seen.
at the ductal orifice prior to passing a canula
7. In Sjgren's syndrome 'fruit laden branchless
connected by extension tubing to a syringe like
tree' or 'cherry blossom' appearance is seen.
ethiodol or non-lipid soluble like sinography
contrast solution is slowly infused until the patient
SURGICAL TREATMENT OF
feels discomfort, usually 0.2-1.5 ml depending
SALIVARY GLAND DISORDERS
on the gland to be studied. Fluoroscopic
monitory or a series of conventional radiographs I. Transoral sialolithotomy of submandibular
are taken. The syringe containing the contrast gland (Figs 16.3 and 16.4):
agent is taped to the patient's chest or shoulder, a. It is a process done under local anesthesia
outside the area of interest. Normally the image and in sitting position.
of the ductal system appears as tree limbs with b. Preoperative radiograph and palpation of
no area of gland devoid of ducts. The gland is the gland is done to locate the exact site
allowed to empty for five minutes. If imaging of stone and duct.
suggests contrast retention, a sialogouge solution c. The tongue is tied and retracted to prevent
such as lemon juice or 2 percent citric acid may it from falling back
be administered to augment the emptying phase d. A suture is placed behind the stone to
by stimulating secretion. prevent to the slipping of stone more
posteriorly.
Significance of Sialography e. Push the gland extraorally to make the
stone palpable from intraoral site.
1. It is contraindicated in acute sialodenitis
f. Make a longitudinal incision over the stone
2. In chronic sialadenitis, the sac like acinis and
with proper care to pressure the
ducts are mildly dilated.
sublingual gland and lingual nerve.
3. In sialodenosis, the gland appears enlarged
g. Milking of duct is done to retrieve the
4. The early cystic lesions are visualized
stone by a small forceps or in case of larger
stones; it is crushed and retrieved in
pieces.
h. Proper irrigation of the area is done
followed by suturing only at the level of
the mucosa (duct should not be sutured
otherwise compression of duct occurs and
a fistula results).
II. Transoral sialolithotomy of parotid gland
(Fig. 16.5):
1. Access to parotid gland stone is difficult
than submandibular gland stone due to
the anatomic peculiarity of the parotid
gland.
2. Direct incision over the stone is possible
Fig. 16.2: Sialographic view of parotid only if the stone is present anterior to
gland and its ducts massetric muscle but in most of the cases
Fig. 16.3: Transoral sialolithotomy of Fig. 16.4: Submandibular gland duct

submandibular gland opened and stone located
the stone is present posterior to massetric and the lingual nerve, the submandibular
muscle, so it is difficult to reach it. In this gland is made free from all its attachments.
case a semi lunar incision running from Now the gland is removed and proper
above downward in front of caruncle is postoperative care is taken.
made. The caruncle, mucosal flap, and
duct are retracted medially and the cheek
is retracted laterally.
3. Now direct access is got to the duct. A
blunt longitudinal dissection is done lateral
to the duct and the stone is retrieved.
4. Irrigation and suturing is done.
Fig. 16.6: Removal of submandibular gland
IV. Removal of parotid gland (Fig. 16.7):

The removal of parotid gland is not
considered to be within the preview of the oral
Fig. 16.5: Transoral sialolithotomy of parotid gland
III. Removal of submandibular gland (Fig.

16.6):
1. In this process a 5 cm long extraoral
incision is made along the course of the
digastric muscle which is determined by
a curved line joining the mastoid
eminence, the lateral surface of hyoid
bone and the genial tubercle.
2. With proper care to ligate and cut the
facial artery and protect the facial nerve Fig. 16.7: Removal of parotid gland
surgeon, but with special training an oral Increase use of tranquilizers and TCAs
surgeon can be assisting during the procedure. Poor oral hygiene
For this procedure an incision is made from the
superior attachment of the pina downward, turn Clinical Features
anteriorly at the angle of the mandible, and stops i. Mostly unilateral involvement of gland
at the hyoid bone. A second incision made ii. Patient complains of pain in the jaw which
posterior to pinna, joins the first of the inferior worsens while eating and speaking
margin of the pinna. With proper care to protect iii. Tender and enlarged gland
the facial nerve, the gland is made free and iv. Overlying skin is red and warm
removed, and postoperative care is taken. v. Fever, leucocytosis, nausea and fatigue may
be there.
CLASSIFICATION OF SALIVARY
Treatment
GLAND DISORDERS
i. The condition is treated aggressively with
I. Developmental antibiotics before the features worsen.
II. Inflammation (sialadenitis): ii. Adequate hydration and electrolyte balance
i. Acute or chronic bacterial sialadenitis is maintained with IV fluids.
ii. Viral sialadenitis iii. Salivation is stimulated by sucking of sour,
III. Obstructive and traumatic lesion hard candy.
i. Sialolithiasis iv. In severe conditions surgical drainage of
ii. Mucocele and Ranula gland is considered.
IV. Functional disorders
i. Xerostomia 2. Chronic bacterial sialadenitis:
ii. Ptylism (sialorrhea) Etiopathogenesis:-
V. Neoplastic lesions: Bacteria's like Streptococcus viridans, E.Coli,
i. Benign lesions Proteus, pneumococci invade the salivary gland
ii. Malignant lesions especially under the following conditions:
VI. Autoimmune conditions i. Ductal obstruction
i. Sjgren's syndrome ii. Sjgren's syndrome
iii. Predisposing viral injections
STUDY OF SALIVARY GLAND iv. Allergy
DISORDERS v. Idiopathic
Clinical Features
I. Bacterial Sialadenitis
i. It is condition where recurrent parotitis
These are inflammatory condition of the salivary occurs with unilateral jaw swelling and
gland caused due to bacterial inversion. They patient shows history of similar recurrence.
are of two types:- ii. Mild symptoms of pain, fever is there with
1. Acute Bacterial Sialadenitis: purulent material which can be milked from
Etiopathogenesis:- Stensons duct's orifice.
Bacteria like Staphylococcus aureus,
Streptococcus aureus, Streptococcus viridans Treatment
and Actinomyces species invade the salivary gland i. Conservative measures of hydration
especially under the following conditions. massage and use of silogouges and
Decreased salivary flow antibiotics are mostly enough.
Deliberated heath of patient ii. Rarely surgical drainage may be needed.
II. Sialolithiasis
It is a condition where there is inflammation of
a sialolith. A sialolith is calcified organic crystalline
structure composed of layers of organic matter
covered with concentric shells of calcified matter.
This sialolith develop in the parenchyma or ducts
of the major or minor salivary glands.
Etiopathogenesis
Sialolith formation occurs due to a combination
of several factors. These are:
Inflammations of the gland
Local irritants
Drugs that causes stasis leading to build up Fig. 16.8: Radiographic view of
submandibular gland stone
of an organic nidus that finally calcifies.
Most of the sialolith are formed in the
Treatment
submandibular gland or its duct as:
Wharton's duct contains sharp curves likely Acute infection due to stasis is treated by
to trap mucus plug or cellular debris. antibiotics.
Calcium levels are more in saliva from In case of stone in the distal portion of the
submandibular gland. duct, it is removed manually.
The position of the submandibular gland In other conditions transoral sialolithotomy
increases the chance for stasis. is done as described earlier.
Clinical Features
III. Mucocele and Ranula
Painful, intermittent swelling in the area of
It is a cystic swelling of the salivary gland
a major salivary gland, which worsens during
caused due to extravasations or retention of the
eating and resolves after meals. This pain is
saliva. A detailed description of the condition
due to accumulation of saliva behind the
has been done in the chapter of the 'cysts of
stone.
the oral cavity' (Fig. 16.9).
The stasis of saliva may lead to infection,
inflammation, fibrosis, or atrophy of the
glandular parenchyma.
In chronic cases sinus tracts, fistulas and
ulceration over the stone may be formed.
In case of sialolith present in the Stenson's
or Whaton's duct, it may be palpable. But
in minor salivary glands they are rarely painful
and may even be asymptomatic.
Diagnosis
Best done by combination of clinical evaluation,
radiographs and sialography along with Fig. 16.9: Clinical view of ranula of submandibular
ultrasonography (Fig. 16.8). gland (For color version see plate 4)
IV. Neoplastic Lesions (tumors) v. Canalicular adenoma.

of the Salivary Gland vi. Ductal papilloma.
2. Malignant tumors:
Classification of salivary gland tumors : i. Mucoepidermoid carcinoma
1. Benign tumor: ii. Adenoid cystic carcinoma (ACC)
i. Pleomorphic adenoma iii. Malignant pleomorphic adenocarcinoma
ii. Warthin's tumor iv. Serous cell adenocarcinoma
iii. Basal cell adenoma. v. Acinar cell tumor
iv. Myoepithalioma vi. Undifferentiated carcinoma.
Sl.No. Name of tumor Etiopathogens Clinical features Histological features Treatment
1. Pleomorphic The mucoepidermoid - Mostly affects females in - Clear well defined - Complete
adenoma cells, basket cells or 4th to 6th decade of life. capsule with a variety of removal of the
intercalated duct cells - Parotid gland is mostly cells are seen. involved gland
shows metaplasia and affected. with the
leads to various types - Starts as small swelling and overlying
of tissues grows to form firm, mucosa.
palpable nodular swelling. -Prolonged
- No other features are radiotherapy can
seen. also be done.
2. Warthins tumor Arises from the - Mostly affects adult male. - There is a cystic - Surgical removal
proliferation of mass - Parotid gland is affected. formation having of the gland
formed by entrapment - it appears as painless, eosinophilic coagulation
of salivary gland small nodule like swelling in the centre with
tissues within the intra which is firm and rough papillary projections
parotid and para like in consistency. formed by two epithelial
parotid lymph nodes layers and lymphatic
during embryogenesis. tissues.
3. Mucoepidermoid It contains both mucus - seen in children and - It shows mucous cells, - Surgical removal
carcinoma secreting and adults. epidermoid cells, and of the gland
epidermoid cells. - Mostly affects parotid intermediate cells. followed by radio-
gland. therapy.
- can be low grade as well
as high grade.
- Low grade is a slowly
enlarging painless mass
reversibility, mucocele.
- High grade is aggressive,
painful mass which is fixed
and may be ulcerated and
even spreads to adjacent
tissues.
4. Adenoid cystic -------- - Mostly seen in old age. - 'Honey count' or 'Swiss - Surgical removal
carcinoma - Parotid gland is mostly Cheese' appearance is of the gland
affected. seen formed by basal cells followed by
- Pain with localized which surround cystic radiotherapy.
discomfort and ulceration is spaces having mucoid
seen. cells.
- Facial nerve paralysis is
also seen.
V. Sjgren's Syndrome 3. Rose Bengal dye test: It is used to detect the

damaged and denuded areas on the cornea.
It is an autoimmune disorder of exocrine glands
4. Salivary flow rate examination: Secretion of
that may be associated with other connective
0.5 ml saliva or less in a minute is seen in
tissue disease, neuropathy and lympho
Sjgren's patient.
proliferative disorders.
5. Salivary gland biopsy is done for histo-
Types pathological examination.
6. Sequential scitigraphy
Primary Sjgren's syndrome Affects the 7. Radiographic examination
exocrine glands only ( lachrymal and salivary 8. Sialography technique.
gland)
Secondary Sjgren's syndrome consists of Treatment
salivary gland involvement with an associated
connective tissue disease like rheumatoid Symptomatic treatment with care towards eye
arthritis, SLE, Scleroderma and polymyositis. disorders and connective tissue disorders is done.
Clinical Features COMPLICATIONS OF SALIVARY

1. Mostly affects middle aged and elderly GLAND SURGERY
females.
1. In case of intraoral approach:
2. Patient complains of dry eyes with a feeling
i. Anesthesia and paresthesia of the area
of dirt or other foreign body in the eye.
(face).
3. Corneal ulceration, conjunctivitis, dryness of
ii. Damage to the salivary gland duct (Stenson's
larynx, pharynx and nose, lack of secretion
and Wharton's duct)
in the upper respiratory tract is seen.
2. In case of extraoral approach:-
4. Xerostomia, enlargement of submandibular
Frey's syndrome (auriculotemporal
salivary gland and other secondary oral
syndrome)
diseases like candidiasis or increase dental
Facial palsy due to damage to facial nerve.
caries incidence is there.
Salivary fistula formation.
5. Renal involvement, polyneuropathy,
vasculitis and pneumonitis are also seen.
FURTHER READING
Diagnosis 1. Archer WH Oral and maxillofacial surgery, 5th
The diagnosis is done by proper clinical ed, Vol. 2.
2. Daniel M Laskin Oral and maxillofacial surgery,
evaluation along with the following investi-
gations. practice, Vol. 2.
1. Schirmer's test: Here, filter paper is placed 3. Greenberg and Glick Burkets oral medicine,
in the lower conjunctinal sac and the wetting diagnosis and treatment, 10th ed.
of the paper is examined. In a normal patient 4. Gustav O Kruger Textbook of oral and
15 mm of filter paper is wet in 5 minutes, maxillofacial surgery, 6th ed.
whereas in a Sjgren's patient less than 5 mm 5. Omar Abubaker, Keneth Benson Oral and
maxillofacial surgery secrets, 2nd ed.
of filter paper will be wet in 5 minutes.
2. BUT (Break up time test): Here, a slit lamp oral and maxillofacial surgery, 4th ed, 2006.
is placed in front of the patient and the time 7. RA Cawson Essentials of dental surgery and
internal between complete blink and the pathology, 5th ed.
appearance of a dry spot on cornea is noted. 8. Stranding Grays anatomy, 39th ed.
Temporomandibular
Joint Disorders
17
APPLIED ANATOMY AND and shiny and it is covered by a synovial

PHYSIOLOGY OF TMJ membrane lining. It acts to resist any medial,
lateral or inferior forces that tend to separate
Temporomandibular joint is a diarthordial or dislocate the articular surface. Also, it
synovial joint present at both sides of head and encompasses the joint, thus retaining the
is composed of articulating surface, articulating synovial fluid.
disc and ligaments. It is classified as b. Collateral ligament (distal ligament): This
ginglimodiarthroidal joint, namely a joint that is ligament resists the movement of the disc
capable of hinge type movement (ginglimos) away from the condyle, as it slides anteriorly
and gliding movement, with the bony and posteriorly.
component enclosed and connected by a fibrous c. Temporoamandibular ligament (lateral
capsule.
ligament): This ligament gives strength to the
lateral aspect of the fibrous capsule and resists
i. Articulating Surface excessive dropping of the condyle and
The upper component of the articulating surface therefore acts to limit the extent of mouth
is formed by the articular eminence and anterior opening.
part of glenoid fossa. The lower component is d. Sphenomandibular ligament: This is an
formed by the condylar head of mandible. accessory ligament which does not have any
significant effect on mandibular movement.
ii. Articular Disc e. Stylomandibular ligament: This is an
accessory ligament which limits the excessive
It is biconcave fibrous disc with thick anterior protrusive movements of mandible.
and posterior bands and thin intermediate zone. f. Mandibular malleolar ligament: This is an
It divides the joint space into upper and lower
accessory ligament which does not have any
component. It acts as a shock absorber in the
significant effect on mandible movement.
TMJ.
NERVE AND BLOOD
iii. Ligaments
SUPPLY OF THE TMJ
TMJ ligaments are four in number. They are
a. Fibrous capsule (capsular ligament): It is Nerve Supply
fibroelastic sac encompassing the entire TMJ. It is innervated by the branches of auriculo-
The inner surface of the capsule is smooth temporal nerve, massetric nerve, and the
Development of the TMJ

It develops in 10th and 12th intrauterine week.
At 10th intrauterine week mesenchyme appears
in between the condyle and temporal bone. At
12th intrauterine week the articular disc with
innervations appears.
Functional Movements of TMJ

Fig. 17.1: Anatomy of temporomandibular joint
The movements of the TMJ can be divided into
posterior deep temporal nerve, which are two kinds:
branches of the Mandibular portion of the i. Involving articulating surface and disc.
trigeminal nerve. ii. Involving articulating disc and condyle.
The movements are:
Vascular Supply a. Elevation (Jaw closing)
It comes from the branches of the superficial b. Depression
temporal arteries, deep auricular arteries, anterior c. Protrusion
tympanic arteries and ascending pharyngeal d. Retrusion
arteries. e. Lateral excursive movements.
MUSCLES RELATED TO THE TEMPOROMANDIBULAR JOINT
Sl.No. Features Temporalis Masseter Medial pterygoid Lateral pterygoid

muscle muscle muscle muscle
1. Origin Temporal lines Zygomatic arch Pterygoid process of Pterygoid process of
sphenoid. sphenoid.
2. Insertion Coronoid process Lateral surface of Medial aspect of Slightly anterior to
mandibular ramus mandibular angle. mandibular condyle.
and angle.
3. Nerve supply Trigeminal nerve, Trigeminal nerve, Trigeminal ner ve, Trigeminal nerve,
mandibular branch mandibular branch mandibular branch mandibular branch
(divided branch) (divided branch) (main trunk) (divided branch)
4. Action Elevates mandible for Elevates mandible; Elevates mandible; Protracts mandible;
biting and chewing; produces forceful bite produces lateral produces lateral
retracts mandible. and some lateral excursion. excusion.
excursion.
5. Clinically pain Temple, maxillary Mandible, maxillary TMJ, retromandibular TMJ
refers to teeth, TMJ. molar, TMJ, ear. area, tongue.
6. Clinical effect Restriction of mandi- Same as temporalis. Restriction of Contralateral
bular opening, ipsi- mandibular deviation of the
lateral deviation of movements, contra mandible, protrusion
mandible, deviation of lateral deviation of of condyle, acute
interocclusal space. mandible. malocclusion.
Temporomandibular Joint Disorders 203
H. Drug induced
1. Steroid
II. Extracapsular
1. Psychophysiologic (myofacial pain
dysfunction syndrome -MPDS)
2. Iatrogenic
3. Traumatic
4. Those referred from local dental origin
5. Infection
Fig. 17.2: Muscles of mastication
6. Otologic
7. Neoplastic
CLASSIFICATION OF TMJ
DISORDERS (BY WELDON BELL) DIAGNOSIS OF TEMPORO-
MANDIBULAR JOINT DISORDERS
I. Intracapsular
The diagnosis of TMJ disorders is done by the
A. Degenerative joint diseases. combination of following method:
1. Osteoarthritis. 1. Proper history taking
B. Inflammatory 2. Clinical evaluation
1. Rheumatoid arthritis (and other collage i. Inspection of:
disorders) - Dental examination
2. Psoriatic arthritis - Occlusal examination
C. Infection - Mandibular movement.
1. Gonorrhea ii. Palpation:
2. Spread from contiguous sites - Muscle tenderness
3. Tuberculosis - Ear pain
4. Syphilis - Neurological examinations
D. Developmental
iii. Auscultation
1. Condylar hyperplasia
- Clicking sound
2. Condylar hypoplasia
- Crepitus sound.
3. Agenesis
3. Radiological investigation:
E. Traumatic
i. Plain radiography
1. Condylar fracture
- Transcranial view
2. Ankylosis
3. Dislocation - Transpharyngeal view
4. Disc displacement - Transorbital view
F. Metabolic - Reverse Towne's projection
1. Gout - Water's projection
G. Neoplasia ii. Tomography
1. Benign - provides a series of radiographs and
2. Malignant depicts a greater portion of the joint.
iii.Arthography:
Defects of the soft tissue derangement and
disc joint can be determined by
arthrography. Here, water soluble iodine
containing contrast material is injected into
the lower joint space and radiograph is
taken to better visualize the area.
iv. Arthroscopy:-
Visualization and diagnosis of the
arthrosis, inflammatory diseases-arthritis, Fig. 17.3: Blairs incision
remodeling, adhesion and perforation of
the TMJ can be done by arthroscopy
technique. Besides, synovial biopsies can
also be done.
v. Magnetic resonance imaging (MRI)
Ionizing radiations are used to determine
the TMJ disorders.
vi. Electromyography:-
Provides an objective means of
monitoring changes in muscle activity and
is helpful in diagnosing myofacial pains. Fig. 17.4: Dingmans and Moorans incision
It is an important component of bio
feedback treatment for myofacial pain.
vii. Cinefluroscopy- attachment of the lamina of tragus and
Dynamic depiction of the soft tissue superior aspect, reflecting this cartilage
components of the joint are produced anteriorly and down over itself (Fig. 17.4).
while in function by the help of relatively 3. Rowe's extended Blair's incision or Thoma's
low level of radiations. augulated incision: This incision is a
4. Laboratory investigation:- modification of Blair's incision, which also
Biochemical and serological tests are done resembles the original preauricular incision
to diagnose the infective and metabolic disorders of Thoma (Fig. 17.5).
of the TMJ.
SURGICAL APPROACHES TO THE

TEMPOROMANDIBULAR JOINT
The surgical approaches to expose the
temperomandibular joint area are:
1. Blair's Inverted hockey - stick Incision
(inverted L): It commences from the
temporal hairline and curving downwards
to the anterior auricle (Fig. 17.3).
2. Dingman's and Moorman's Incision: This
incision sections the minor fibrous Fig. 17.5: Rowes incision
Fig. 17.6: Preauricular incision Fig. 17.8: Alkyat-Bramely incision
Fig. 17.7: Modified preauricular incision Fig. 17.9: Risdons incision
4. Preauricular incision and modified slightly behind the angle of the mandible.
preauricular incision: This the basic incision This approach provides poor access to the
for temperomandibular joint ankylosis; This condylar head region (Fig. 17.9).
incision passes through avascular area and 7. Hind's postramal incision: Excellent cosmetic
reduces operating time, postoperative procedure recommended by hind, for
edema, patient discomfort and gives good surgeries involving the condylar neck and
cosmetic results (Figs 17.6 and 17.7). ramus area (Fig. 17.10).
5. Alkyat- Bramely incision: This is a question 8. Popowich's and Crane's modification of
mark shaped incision for maximum visual Alkyat Bramely question mark incision: It
and mechanics access (Fig. 17.8). is a modification Alkyat Bramely incision
6. Risdon's submandibular incision: The recommended by Popowich and Crane.
incision is given about 1cm below angle of The incision is slightly larger than the former
the mandible. It extends forward parallel incision. This incision provides excellent
to the lower border and curves backward visual and mechanical access (Fig. 17.11).
Fig. 17.13: Post-auricular incision

Fig. 17.10: Hinds incision
provides excellent cosmetic result but limited

access (Fig. 17.12).
10. Post-auricular Incision: The incision starts
from the superior aspect and behind the
external ear and extends to the tip of the
mastoid process. This incision provides
excellent cosmetic result but poor
accessibility and visibility, stenosis, infection
and paraesthesia of the external auditory
canal and deformity of the auricles are also
seen (Fig. 17.13).
Fig. 17.11: Popcowichs incision SURGICAL TREATMENTS OF THE

TEMPOROMANDIBULAR JOINT
1. Eminectomy: It is the removal of the
eminence (Fig. 17.14).
2. Condylectomy: It is the total removal of the
condyle (Fig. 17.15).
3. Modified condylectomy: It is a vertical
ramus osteotomy, whereby the condylar
process is detached from the mandibular
ramus (Fig. 17.16).
4. High condylectomy or condylar shaving: It
Fig. 17.12: Lamports incision is limited bony reconditioning of the head
of the condyle (Fig. 17.17).
5. Plication: It is folding or taking a tuck to
9. Lamport's Endaural Incision: The incision reduce the size of disk (Figs 17.18 and
begins above the zygomatic arch extends 17.19).
downwards and backwards between the 6. Gap arthroplasty and coronoidectomy: It
tragus and the helix and then inward along is a process of removing a section of bone
the roof of the external auditory meatus to create a gap of 1 - 1.5 cm between the
for approximately 1 cm. This incision condylar head and eminence. The glenoid
Fig. 17.14: Eminectomy Fig. 17.17: Condylar shaving
Fig. 17.15: Condylectomy Fig. 17.18: Piece of ligament removed

(Plication step 1)
Fig. 17.16: Modified condylectomy Fig. 17.19: Cut ends of the ligament sutured
(Plication Step 2)
fossa may be recontoured if needed. 7. Costochondral graf ts: These are graft
Coronoid process is removed also (Fig. materials, commonly used in VIIth Rib bone
17.20). of about 1.5 cm or more to replace the
STUDY OF SOME COMMON

TEMPOROMANDIBULAR
JOINT DISORDERS
A. Intracapsular Disorders of TMJ

I. Degenerative Joint Diseases (Osteo-
arthritis):
It is a non-inflammatory degenerative disease
affecting the articular surfaces, accompanied by
Fig. 17.20: Gap arthroplasty and coronoidectomy remodeling of underlying bone.
Etiopathogenesis:
Normal Joint
Repetitive overload Normal load
Functional capacity Functional capacity

exceeded reduced
1. Age
2. RA
3. Idiopathic
Fig. 17.21: Costochomdral graft OREOARTHRITIS
Clinical Features
The features are:
resected condylar process. It is fixed to the Pain in the joint and muscular of mastication
ramus of mandible by stainless steel wiring Spasm of muscle and limitation of mandibular
or screws (Fig. 17.21). movement.
8. Arthrocentesis: It is a process of needle Joint noises, specially "crepitations"
puncture of the joint space; usually this is Females are more affected than males.
combined with lavarge, which is irrigation Features gradually subside in 1 to 3 yrs and
of the joint. finally little or no disability is felt.
9. Arthroscopic surgery: It is an operative
procedure performed with fine instruments Radiographical Features
during telescopic penetration of a joint Subchrondral bony sclerosis or rough or
cavity for diagnosis and therapeutic reasons. woolly appearance is seen near the condylar
The surgery is performed using a rigid region.
endoscope (arthroscope) and is less invasive Subarticular cysts and osteophytes are seen.
than arthrotomy. There is gross destruction of the condyle.
Management Surgical
Non-Surgical High condylectomy

Arthroplasty
Elimination of the cause and prolonged Synovectomy (removal of synovial
physiotherapy and myotherapy with membrane which causes destruction of
occlusal splints is recommended. Systemic cartilage).
and local joint injections of corticosteriodal
are administered along with NSAIDs to III.Infective Joint Diseases (Septic
reduce pain. arthritis):
It is a condition commonly caused by blood
Surgical borne or microorganisms, infection from
adjacent sites like middle ear, maxillary molar
Arthroplasty is done. and parotid gland.
High condyle shaving or condylectomy with
or without TMJ prosthesis is done. Clinical Features
II. Inflammatory joint diseases (Rheumatoid Severe pain and swelling of joint.
arthritis): Inability to occlude teeth.
It is a chronic deliberating autoimmune disease Redness and inflammation of joint
of the joint which spreads from the synovial Large and tender cervical lymph nodes
membrane to the articulating surfaces.
Management
Clinical Features
Joint rest with soft diet, NSAIDs and antibiotics
TMJ is bilaterally affected. are recommended. Surgical drainage of pus, if
Dull deep pain, tenderness, stiffness and present.
limited mandibular movement are seen,
especially in early morning. IV. Developmental Joint Disorders
Swelling of joint
Joint sounds heard on auscultation. 1. Condyle Hyperplasia
The features gradually subside as the lesion It is a unilateral or bilateral increase in the condyle
becomes more chronic. growth due to local or systemic causes.
Radiographic Features Features

Destructive lesion with narrowing of joint Limited mouth opening with occasion pain
space is seen. in the TMJ.
Deviation of mandibular to the effected side
Management with facial asymmetry.
Treated by orthognathic surgery, without any
Non Surgical
permanent facial deformities, if done at an
Joint rest, soft diet, NSAIDs are recommended early age.
along with intra lesional corticosteroid injection Condylectomy or condyloplasty may also be
in acute phase. done in some mild cases.
Fig. 17.22: 3D view of condylar hyperplasia
2. Condyle Hypoplasia
It is a unilateral or bilateral decrease in the
condyle growth due to local or systemic causes Fig. 17.23: 3D view of ankylosis
(Fig. 17.22). (For color version see plate 4)
Features
Limited mouth opening with occlusion Etiology of Ankylosis of TMJ
deviation and facial deformity is seen
Treated by graft surgeries with or without 1. Trauma: Intracapsular fracture in children and
cosmetic improvement. medically displaced condyle fracture.
2. Infection: Infections of the middle ear (otitis
V. Traumatic Joint Diseases: media) and septic arthritis.
Ankylosis 3. Inflammation: Rheumatoid arthritis
4. Surgery: Postoperative complication following
It is an intracapsular condition where there is TMJ surgery.
fusion of the bony surfaces of joint like condyle 5. Congenital: Rarely caused congenitally but
to glenoid fossa (Fig. 17.23). may be due to congenital syphilis and
intrauterine injuries.
Types of Ankylosis
I. Based on cause: Clinical Features
1. Fibrous ankylosis (Restricted mouth
opening due to fibrous transformation of 1. In unilateral ankylosis:
the articular disc. a. Deviation of chin and mandibular on the
2. Bony ankylosis (True fusion of bony parts affected side leading to facial asymmetry.
of joint) b. Hypoplasia of mandible on the affected
II. Based on location: side.
1. Unilateral only one of the joints effected c. Well defined antegonial notch on the
2. Bilateral both joints are affected. affected side.
d. Flat and elongated unaffected side. Treatment of fibrous ankylosis: This is treated by
e. Limited mouth opening. applying brisement force under general
f. Class II malocclusion on affected side with anesthesia.
posterior crossbite on the ipsilateral side.
Treatment of bony ankylosis: Kaban, Pinnot and
2. In Bilateral ankylosis:
Fisher protocol for management of bony
a. 'Bird facies' deformity - symmetrical and
ankylosis of TMJ.
micrognathic mandible.
1. Early surgical intervention.
b. Antegonid notch present bilaterally.
2. Aggressive resection of gap of at least 1-1.5
c. Class II molecular and crowding with
cm should be created (Interposition gap
anterior open bite and protrusive incisions.
arthroplasty).
d. Restricted mouth opening.
3. Ipsilateral coronoidectomy and temporalis
Investigation myotomy.
4. Contralateral coronoidectomy and temporalis
It is done mainly by various radiographic myotomy if mouth opening is less than 3-
techniques as described earlier (Fig. 17.24). 5 mm.
5. Lining of glenoid fossa region with temporalis
Management
fascia.
Treatment objectives are: 6. Reconstruction of the ramus with
1. To improve joint movement and function. cortocondral graft.
2. To restore vertical height of face. 7. Early mobilization and aggressive
3. To restore mandibular growth in case of physiotherapy for at least six months.
ankylosis of TMJ in children below five years 8. Regular long term follow up.
(cortochodral grafts are used). 9. To carry out cosmetic surgery at the late date
4. To prevent recurrence. when the growth of the patient is completed.
(orthognathic surgery)
Complications
1. Operative
i. Anesthetic complicated
ii. Hemorrhage
iii. Damage to external auditory meatus.
iv. Damage to facial nerve.
v. Damage to glenoid fossa.
vi. Damage to auricular temporal nerve.
vii. Damage to parotid gland.
viii. Damage to teeth and jaws.
2. Postoperative
i. Infection
ii. Open bite
iii. Recurrence; caused due to:
a. Inadequate gap created
Fig. 17.24: Radiographic view of ankylosis b. Improper gap arthroplasty
c. Fracture of costochondral graft 2. Extrinsic causes:

d. Loosening of costochondral graft. i. Drug induced:
e. Inadequate covering of glenoid fossa. - Phenothiazine (because of extrapyrimidal
f. Inadequate post operative physiotherapy action)
ii. Trauma:
VI. Dislocation and Subluxation: - During intervention with GA and mouth
Dislocation or luxation occurs when the condyle gags
moves into a position anterior to articular - Endoscopy
eminence from which it cannot be voluntarily - Dental entractions
reduced.
Subluxation or hyper mobility is a self limiting Clinical Features
incomplete dislocation, which generally follows 1. On inspection:
stretching of the capsule and ligaments. i. Inability to close mouth, mouth held open
and mandible deviated in unilateral cases
Types of Dislocation and mandible protruded in bilateral cases.
ii. Excessive salivation and pain in TMJ.
I. Based on duration:
2. On palpation: Preauricular depression on
1. Acute or luxation skin.
2. Long standing dislocation
3. Chronic/habitual/recurrent luxation or Investigations
Hypermobility or subluxation.
This is mainly done by the clinical features along
II. Based on location:- with radiograph evaluation (Fig. 17.25).
1. Unilateralonly one joint involved
2. Bilateralboth joints involved.
III. Based on position:-
1. Anterior dislocation
2. Posterior dislocation
3. Superior dislocation
4. Medial dislocation
5. Lateral dislocation
Predisposing factors for the cause of dislocation:

1. Thin ligament and capsule
2. Flattened articulating eminence
3. Shallow fossa Fig. 17.25: Radiographic view of dislocation
4. Parkinsonism
5. Rubber man (Ehlers-Danlos syndrome) Management
Etiology of dislocation of TMJ: The choice of treatment depends on the type
1. Intrinsic trauma: of dislocation and the features present.
Over extension injuries like- 1. In case of acute dislocation (luxation):-
i. Chewing Manual reduction as described by Hippo-
ii. Vomiting cratus is the treatment of choice. In case of
iii. Wite biting extreme muscle trismus or reduced mouth open-
iv. Seizure disorders ing reduction is done under local anesthesia,
v. Yawning general anesthesia or skeletal muscle relaxants.
In this procedure, the operator's thumbs are notch or wire fixed to lower border of
placed over the patient's molar area and other mandible.
fingers are placed over anterior chin area. Force iii. Osteotomy and condylectomy procedure
is applied on the mandible in the downward - are also practiced in cases where only
posterior direction to disengage the condyle reduction is not sufficient.
from its open locked position posterior to the 3. In case of chronic/habitual/recurrent luxation
articular eminence (Figs 17.26A and B). or hypermobility or subluxation the treat-
2. In case of long standing dislocation the ment done is:
treatment done are: i. Conservative approach by injecting
i. Manual reduction with or without jaw sclerosing agents by arthroscopy
immobilization for a certain period to allow technique into the TMJ to cause capsule
muscle and ligament adaptation by inter shrinkage. These agents are 5 percent
maxillary fixation. sodium psylliate or 5 percent intracaine
ii. In cases where manual reduction is not in oil base.
effective, reduction is done by pulling the ii. Manual reduction with or without jaw
mandible downward with the help of immobilization by intermaxillary fixation.
reduction hook placed in the sigmoid iii. Eminectomy for removal of obstructing
articulating eminence in the path of
condyle movement.
iv. Ligament and capsule plication for easy
condyle movement.
v. Lateral pterygoid myotomy to limit the
pressure exerted by lateral pterygoid
muscle into the mandible.
vi. Restricting the movement of the condyle
by creating a mechanical obstruction for
condyle movement. This is done either
by fracturing the articulating eminence
(A)
and pushing it downward (Girard's
method) or by fracturing the zygomatic
arch and pushing it laterally and
downward (Doutry's method).
vii. Placement of bone graft material onto the
condyle or its path to limits its movement.
B. Extracapsular Disorders of TMJ

I. Myofunctional pain dysfunction
syndrome (MPDS): Travell asserted that a
vast majority of the patient with pain in the
region of TMJ were suffering from a functional
disorder involving on painful self perpetuating
spasm of masticatory muscle. This condition
(B) of pain, dysfunction and muscle spasm of
Figs 17.26A and B: Bimanual reduction in luxation the masticatory muscles is called as MPDS.
Etiopathogenesis 2. To apply warm and moist compression over

the involved muscle, three times a day for
15-20 minutes.
3. Soft diet and restricted mouth opening.
4. NSAIDs are recommended
During the following visits the following are
done:
1. Injecting local anesthesia into the muscle that
are spasm.
2. To relieve pain ethyl chloride spray can be
used and ultrasound can be used to relieve
spasm.
3. Jaw exercises are recommended.
4. Drugs like antidepressants to reduce anxiety,
tranquilers for psychoses and sedatives and
hypnotics for reducing pain can be given.
5. Occlusal adjustments and occlusal splints are
recommended.
6. Bio feedback is used to provide patient with
Clinical Features information concerning bodily function that
are not usually controlable.
Four cardinal signs of MPDS by Laskin
7. Transelectrical nerve stimulation (TENS) is
1. Unilateral vague pain in the ear or
used to reduce pain.
preauricular area that commonly worsen on
8. Arthrocentosis can be done to lavarge the
awakening.
TMJ and increase the joint mobility.
2. Tenderness of one or more muscle of
9. Acupuncture and other nerve treatment
mastication on palpation.
choices can also be used to reduce pain and
3. Clicking or popping noise in the TMJ.
other symptoms.
4. Limitation or deviation of the mandible on
opening. FURTHER READING
Laskin emphasized that the patient must also 1. Archer WH Oral and maxillofacial surgery, 5th
have the following negative characteristics: ed, Vol. 2.
1. Absence of clinical, radiographic or biological 2. Bell WE Temperomandibular disorders, 3rd ed.
evidences of organic changes in the TMJ. 3. Bush, Dolwick The temperomandibular joint
2. Lack of tenderness in TMJ area, on palpation and related orofacial disorders.
via the external auditory meatus. 4. Hermann S Sailer Transplantation of
lyophilised cartidage in maxillofacial surgery -
experimental foundations and clinical success.
Management 5. Jeffrey P Okeson Management of
MPDS management is done by proper managing temperomandibular disorders and occlusion, 5th
ed.
the emotional as well as physical components.
In the initial visit the following are done: oral and maxillofacial surgery, 4th ed, 2006.
1. Patient is educated and advised to limit para 7. Sanders, Murakami, Clark Diagnostics and
functional habits like clenching and grinding surgical arthroscopy of the temperomandibular
of teeth during the day. joint.
Orthodontics 18
Orthodontic Surgery
Orthodontic surgeries refers to the surgical derotated position, the relapse can be
procedures carried out as an adjunct or in avoided. In this procedure, a no. 11 B.P
conjunction with orthodontic treatment. These blade or narrow scalpel is passed through
surgical procedures are usually carried out to the gingival sulcus to a depth of 2 mm apical
eliminate an etiologic factor or to correct severe to the alveolar crest on all the surfaces of
dento-facial abnormalities that cannot be the derotated tooth. This procedure is done
satisfactory treated by growth modification as an adjuvant retention procedure after
procedures or orthodontic camouflage. correction of rotation.
Various surgical orthodontic procedures: II. Corticotomy:
1. Orthodontic extractions Corticotomy is a surgical procedure usually
2. Surgical uncovering of teeth undertaken in patients having dental
3. Frenectomy proclination with spacing. This procedure
4. Pericision involves the sectioning of the dentoalveolar
5. Transplantation of teeth region into small units to hasten orthodontic
6. Corticotomy tooth movement. Here interdental bony
7. Orthognathic surgery cuts are made parallel to the long axis of
8. Surgical corrections in cleft lip and palate the tooth. Which may be joined together
patients. by horizontal bony cuts above the apices
9. Surgical assisted rapid maxillary expansion. of the roots. Following this surgery,
orthodontic tooth movement is initiated
STUDY OF SOME ORTHODONTIC using fixed appliances.
SURGICAL PROCEDURES III. Orthognathic surgery:
Orthognathic surgery is the surgical
I. Pericision:
correction of skeletal anomalies or
Pericision or circumferential supra-crestal
malformations involving the mandible or
fibrotomy is done to prevent the relapse
maxilla.
tendency of the stretched gingival fibres in
case of orthodontic derotation. If this Indications of orthognathic surgery:-
supracrestal fibres i.e the trans-septal and Orthognathic surgery is used to correct any
alveolar crest group of fibres are sectioned severe dentoalveolar discrepancy which is too
and allowed to heal according to the severe for being corrected by orthodontics alone.
Contraindications of orthognathic surgery:-

Orthognathic surgery is not done in severe
systemic and general health deproved patients.
Goals of orthognathic surgery:-
1. To restore normal masticatory, speech, ocular
and respiratory functions.
2. To restore normal facial harmony and
Fig. 18.1D: Retrognathic mandible
balances
3. To prevent short and long term relapse of
orthodontic treatment
4. To minimize the treatment time.
Basic forms of facial deformities:-
The basic forms of dental deformities are:
1. Along the anteroposterior dimension:-
Fig. 18.1E: Prognathic mandible
Fig. 18.1A: Prognathic maxilla
Fig. 18.1F: Apertognathia
2. Along the vertical dimension:-

Fig. 18.1B: Retrognathic maxilla
Fig. 18.1C: Bimaxillary protrusion Fig. 18.2A: Maxillary excess
Surgical Procedures in OrthodonticsOrthodontic Surgery 217
Fig. 18.2B: Mandibular excess
Fig. 18.3B: Maxillary transverse deficiency
Fig. 18.2C: Mandibular deficiency
Fig. 18.3C: Facial asymmetry
Pre-operative diagnosis and evaluation: A

proper pre-operative diagnosis should be done
for planning the surgical procedure. This is done
Fig. 18.2D: Maxillary deficiency
by the combination of the following methods:
1. Clinical examination of the medical health
3. Along transverse direction:- of the patient, local examination of the hard
and soft tissues.
2. Socio-psychological evaluation to know about
the patient's desires, need and knowledge
towards the procedure.
3. Radiographic evaluation by intraoral and
extraoral radiographs to evaluate the dental
conditions and supportive bone.
4. Cephalometric evaluation to determine the
skeletal discrepancies present and plan the
surgery needed.
5. Study model evaluation is done to evaluate
three-dimensional inter-arch, intra-arch and
Fig. 18.3A: Maxillary transverse excess occlusal discrepancies.
Facial Symmetry Assessment
Fig. 18.4: Facial symmetry assessment
Features of Maxillofacial Deformities:
Sl.No. Deformity Clinical features Skeletal features Dental features
1. Maxillary sagittal - Concave facial profile - lower lip thin. - Class III
deficiency - Retrusive upper lip - SNA decreased - maxillary dental
- Acute nasolabial angle - SNB normal crowding
- Alar base narrow - maxillary incisor
- Lack of dental display procline
- Mandibular incisors
normal or retroclined
2. Maxillary sagittal - Convex facial profile - ANB increased
excess - obtuse nasolabial angle. - SNA increased
- SNB normal
Contd...
Contd...
Sl.No. Deformity Clinical features Skeletal features Dental features
3. Maxillary vertical - convex profile - ANB increased - Class II, Class I

excess - lower facial height increased. - lower facial height increased - anterior open bite
- Alar base constricted - SNA decreased - maxillary arch
- Nasolabial angle obtuse - SNB decreased constricted
- Excessive gingival show - ANB increased - curve of Spee, flat
- Excessive incisor show - Mandibular plane angle = steep accentuated
- lip incompetence - palatal-occlusal plane increased - dental crowding.
- mentalis strain with lip closure
- chin vertically long, retruded.
4. Maxillary vertical - concave facial profile - lower facial height decreased - Class II, class I
deficiency - lower facial height decreased. - SNB increased - deep bite
- Nasolabial angle acute. - ANB negative - curve of Spee is reverse.
- Alar base widened. - palatal occlusal plane decreased - crowding
- lack of incisor show - Mandibular plane angle =
- edentulous appearance acute
- chin protruded.
5. Mandibular deficiency - convex profile - SNA normal - Class II
- retruded chin - SNB decreased - Mandibular incisor
- deep labio-mental crease - ANB increased proclined
- mentalis strain with lip closure - Ar-Gn decreased - maxillary incisor
- lower lip everted retroclined
- curve of Spee
accentuated
6. Mandibular excess - lower lip everted - SNA normal - Class II
- concave profile - SNB decreased - maxillary incisor
- midface appears deficient - ANB decreased proclined
- lower third broad - Mandibular incisors
- lower lip thin retroclined.
Different orthognathic surgical pro- ii. Mandibular anterior subapical segmental

cedures:- osteotomy
1. Procedures to correct maxillary excess; iii. Vertical ramus osteotomy
i. Anterior maxillary osteotomy by iv. Sagittal split osteotomy
Wassmund's technique or Wunderer's 4. Procedures to correct Mandibular deficiency:
technique i. Vertical osteotomy of maxilla and inter
ii. Total maxillary osteotomy positional bone graft
iii. Maxillary segmental osteotomy ii. Modified 'C' osteotomy
2. Procedures to correct maxillary deficiency; iii. Total subapical osteotomy
i. Le fort I advancement osteotomy iv. Mandibular inferior border osteotomy
ii. Inferior repositioning of maxilla and inter (genioplasty)
positional bone graft. v. Inverted 'L' osteotomy
iii. Le fort III osteotomy 5. Procedures to correct facial asymmetry:
3. Procedures to correct Mandibular excess: i. Maxillary and Mandibular osteotomy,
i. Mandibular body osteotomy genioplasty and inferior border recontouring
Explanation of Various
Osteotomy Procedures
1. Procedures to correct maxillary excess:
(maxillary prognathism)
i. Anterior maxillary osteotomy by
Wassmund's or Wunderer's technique:
Anterior segment of the maxilla is
repositioned to a retruded position by
making it mobile. A bilateral vertical
incision is made from canine region to
nasal aperture from buccal sulcus and the Fig. 18.7: Post-treatment anterior
palatal flap is tunneled to make the seg- maxillary osteotomy
ment mobile, which is repositioned after
ii. Total maxillary osteotomy:-
removal of 1st premolar. (Wassmund's
technique) (Fig. 18.5). A bilateral trans-
verse incision is made from 1st premolar
region to nasal aperture from buccal
sulcus and the palatal flap is tunneled to
make the segment mobile, which is reposi-
tioned after removal of 2nd premolar
(Wunderer's technique) (Fig. 18.6).
Fig. 18.8: Pre-treatment maxillary prognathic
Fig. 18.5: Wassmund technique
Fig. 18.9: Post-treatment Total maxillary

osteotomy
iii. Maxillary segmental osteotomy (closure

Fig. 18.6: Wunderer technique of tooth space):-
ii. Inferior repositioning of maxilla and

interpositional bone graft
Fig. 18.10: Post-treatment Maxillary segmental

osteotomy
Fig. 18.13: Pre-treatment Retrognathism
2. Procedures to correct maxillary deficiency: maxillary
(Maxillary retrognathism)
i. Le fort I advanced osteotomy
Fig. 18.14: Post-treatment Interpositional graph
Fig. 18.11: Pre-treatment Lefort I osteotomy iii. Le fort III osteotomy
Fig. 18.15: Pre-treatment Retrognathism

Fig. 18.12: Post-treatment Lefort I osteotomy maxillary
ii. Mandibular anterior subapical segmental

osteotomy:-
Fig. 18.16: Post-treatment Lefort III osteotomy
Fig. 18.19: Pre-treatment Mandibular

3. Procedures to correct Mandibular excess: prognathism
(Mandibular prognathism)
i. Mandibular body osteotomy:-
Fig. 18.20: Post-treatment Subapical

Fig. 18.17: Pre-treatment Mandibular segmental osteotomy
prognathism
iii. Vertical ramus osteotomy
Fig. 18.18: Post-treatment Mandibular body Fig. 18.21: Vertical ramus osteotomy to correct
osteotomy prognathic mandible
iv. Sagittal split osteotomy: Here the ramus

of the mandible is divided by creation of
horizontal osteotomy on medial aspect
and vertical osteotomy on lateral aspect
of mandible. These are connected by
anterior ramus osteotomy. Lateral cortex
of mandible is then separated from
medial aspect and mandible can be
advanced or set back for correction of Fig. 18.23: Interpositioned bone graft
mandibular retrognathism or progna-
thism respectively (Fig. 18.22). ii. Modified 'C' osteotomy
The advantages of this procedure are:
Highly cosmetic (as it is done intraorally)
Broad bony contact of the osteotomised
segments ensure good healing.
There is no need of graft for advance of
mandible. Thus donor site morbidity and a
second operation site (for the graft) is totally
avoided.
The disadvantage is that it demands a high
level of operative skill and experience to minimize
the complication.
Fig. 18.24: Pre-treatment Mandibular
retrognathism
Fig. 18.22: Sagittal split osteotomy to correct

prognathic mandible
4. Procedures to correct Mandibular deficiency:

(Mandibular retrognathism)
i. Vertical osteotomy of mandible and inter Fig. 18.25: Post-treatment Modified C
positioned bone graft: osteotomy
iii. Total subapical osteotomy v. Inverted 'L' osteotomy
Fig. 18.26: Total subapical osteotomy to correct Fig. 18.28: Pre-treatment retrognathism
mandibular retrognathism mandibular
iv. Mandibular inferior border osteotomy

(genioplasty): It is a horizontal osteotomy
procedure of the symphysis region where
the segmental bony section can be either
advanced, reduced, augmented using bone
grafts or straightened to correct retruded
chin, enlarged chin, short chin or protruded
chin respectively (Fig. 18.27)
Fig. 18.29: Post-treatment Inverted L

osteotomy
IV. CLEFT LIP AND CLEFT PALATE

Cleft lip is a birth defect that result in a unilateral
of bilateral opening in the upper lip between
the mouth and the nose. It is also called as harelip.
Cleft palate is a birth defect characterized by
Fig. 18.27: Advancement of chin in short chin an opening in the roof of the mouth caused by
genioplasty a lack of tissue development.
Etiology of Facial Clefts The classification uses a stripped 'Y' having

numbered blocks. Each block represents a
1. Hereditary:-
specific area of the oral cavity.
i. Monogenic theory
Block 1 and 4 lip
ii. Polygenic theory
Block 2 and 5 alveolus.
iii. Multifactorial threshold hypothesis
Block 3 and 6 hard palate anterior to the
2. Congenital:-
incisive foramen
i. Infections:
Block 7 and 8 hard palate posterior to incisive
Rubella, influenza
foramen
ii. Drugs:
Block 9 soft palate.
Cortisone, thalidomide
These boxes are shaded in areas where the
iii. Radiations:
cleft has occurred.
X-rays. R-rays.
iv. Diet:
Deficiency of vitamin B2, folic acid and
increased vitamin A.
Difficulties and Problems

Due to Facial Clefts
1. Psychological problems faced due to
abnormal facial appearance
2. Speech and hearing problems
3. Dental problems of other congenital disease
and abnormal soft and hard tissues.
4. Esthetic problems due to facial disfigurement.
Fig. 18.30: Stripped Y classification
Classification of Orofacial Cleft
I. Veau's classification:
Veau has classified clefts into four groups:
Timing of Surgical Repair
Group 1 : They are clefts involving the soft Cleft lip is generally repaired during 3-4 months
palate only of age. This is done following the rule of 10's.
Group 2 : They are clefts of the hard and soft This rule states - 10 weeks of age, 10 pounds
palate extending upto the incisive of weight, and atleast 10 gm / dl of hemoglobin.
foramen. Cleft palate is generally repaired during 6-
Group 3 : They are complete unilateral clefts 8 months depending on the growth of the baby
involving the soft palate, the hard and surgeon's choice. Early repair of cleft palate
palate, lip and the alveolar ridge. have the following advantages:
Group 4 : They are complete bilateral clefts 1. Better palatal and pharyngeal muscle
affecting the soft palate, the hard 2. Ease of feeding
palate, the lip and alveolar ridge. 3. Better development of phonation skill
II. Kernahan's stripped 'Y' classification: It is a 4. Better hygiene maintaince
symbolic classification put forward by 5. Improved psychologic states for parents and
Kernahan and Stark (Fig. 18.30). baby
But the disadvantages of early closure are: Cheilorrhaphy (surgical

1. Surgical correction is more difficult in correction of cleft lip)
younger children with small structures
2. Scar formation resulting from surgery causes Several types of cleft lip operation have been
maxillary growth restriction. described for unilateral cleft lip. The most
common used operative are Millard's rotation
Management of Orofacial Clefts advancement flap and Tennison-Randall
triangular flap methods. Bilateral cleft lip can be
A multidisciplinary approach involving plastic repaired in two stages by the above mentioned
surgery, orthodontics, speech pathology, procedures or in a single stage by Veau III
neurosurgeon, psychiatrist, oro- maxillofacial procedure, Millard's single stage procedure or
surgeon, ENT department, prosthodontics and black procedure.
pediatrics department is needed to rehabilitate 1. Millard's rotation advancement flap surgery:
the cleft cases. This approach to the problem In Millard's repair rotation flap(a) and
results in esthetically accepted end result without Columella flap (c) as in Fig. 18.31 are
much functional deficiencies. planned on the medial side of the cleft. After
The treatment protocol for management of cleft full thickness of the lip is cut along the
lip and cleft palate is: marking a rotation gap is produced on the
1. At birth pediatric consultation and medial side which is filled by an advancement
feeding instructions are given. flap (b) as in Fig. 18.31 planned on the lateral
2. At 10 -12 weeks Evaluation and surgical side of cleft. In this method the minimal tissue
repair of the lip is done. ( In India, it is is discarded and the result can be modified
performed in 3-6 months). during the surgery (Fig. 18.32).
3. At 12-18 months Evaluation and surgical 2. Tennison- Randall Triangular flap surgery: A
repair of palate and placement of pressure triangular flap is created on the lateral side
equalization tubes is done. of the cleft to fit into the triangular defect
4. At 3-6 years Evaluation and medical produced on the medial side of the cleft (Fig.
treatment, speech therapy, soft palate 18.33). This procedure can be planned
lengthening , fistula repair and psychological exactly after initial measurements. The result
evaluation is done.
5. At 5-6 years lip and nose treatment and
pharyngeal surgery is performed
6. At 7 years phase I orthodontic treatment
is done.
7. At 9-11 years pre alveolar bone graft
are placed
8. At 12 years or later phase II or complete
orthodontic treatment is done
9. At 15 - 18 years In this phase, placement
of implants are done, after completing
orthodontic treatment.
10. At 18-21 years After growth cessation,
surgical advancement of maxilla is done. Fig. 18.31: Incision lines Millards rotation flap
cannot be modified once the lip is cut. The

scar is more prominent than in other
procedure (Fig. 18.34).
3. Veau III single stage procedure: It is the
simplest one stage straight line closure and
produces satisfactory result in a bilateral cleft
lip (Fig. 18.35). In this method vermilion flap
from either lateral side of the cleft is brought
down over the prolabium to augment the
vermilion in the centre of the upper lip (Fig.
18.36).
Fig. 18.32: Sutures placed
Fig. 18.35: Incision line Veau III procedure
Fig. 18.33: Incision lines Tennison randall flap
Fig. 18.36: Sutures placed
Palatorrhaphy (surgical correction

of cleft palate)
Palatorrhaphy can be either done in two stage
where soft palate is repaired before 18 months
followed by obturation of hard palate till hard
Fig. 18.34: Sutures placed palate repair at 4-5 years, or done in one stage.
There are many procedures for single stage DISTRACTION OSTEOGENESIS

repair like Von Langenbeck repair, Veau- Wardill-
It is a process by which controlled and calculated,
Kilner V-Y push back palatoplasty and double
lengthening and widening of bone is achieved
opposing z - plasty of Furlow.
according to need of the patient as per described
1. Veau - Wardill- Kilnar V-Y push back
by the surgeon.
palatoplasty:
In this technique, an appliance known as
Here, two mucoperiosteal flaps are raised
distracter applies gradual force for lengthening
from a hard palate and nasal layers are mobilized.
and widening of the bone.
Abnormal attachments of palatal muscles are
divided from the posterior border of the hard
Indications
palate to be sutured in midline to the opposite
side of the palatal muscle (Fig. 18.38). 1. Unilateral hypoplasia of the mandible
2. Severe retrognathic
3. Non-syndromic Mandibular hypoplasia
associated with dental malocclusion
4. Mandibular hypoplasia due to trauma
5. Mandibular resection
6. Shortened vertical height
7. Maxillary hypoplasia
Contraindications
1. Un-cooperative patients
2. Small fragile bones in the area of placement
of distraction device
3. Atrophied bony areas
Fig. 18.37: Pre-operative Cleft palatal
4. In older- patients
Advantages
1. Distraction osteogenesis produce less pain
and swelling than the traditional procedures
2. It eliminates the need for bone grafts
3. It provides greater stability in major cases
4. Overcorrection is possible
5. No facial surgical incisions present hence
esthetically accepted.
Disadvantages
1. Two visits of the patient to the surgeon is
necessary, to monitor presence of any
Fig. 18.38: Post-operative Palatorrhaphy infection and teach how to activate appliance.
2. A second minor surgical procedure is FURTHER READING

necessary to remove the distraction
1. Archer WH Oral and maxillofacial surgery, 5th
appliance. ed, Vol. 2.
3. In case of extraoral devices, patient co- 2. Barghese Mani Orthognathic surgery: Esthetic
operation is difficult and scars may result. surgery of the face
3. Berkowitz ED Cleft lip and palate, 2nd ed.
Types of Distractors 4. Epker, Stella, Fish Dentofacial deformities
Integrated orthodontic and surgical correction, 2nd
They can be of two types: ed.
1. Extra oral distractors 5. Georgiade, Rieskohl, levin plastic, maxillofacial
2. Intra oral distractors. and reconstructive surgery, 3rd ed.
6. Goldstein Esthetics in dentistry, Vol. 1 and Vol.
2.
7. Harvey M Rosen Aesthetic perspectives in jaw
surgery.
8. Jeffray C Posnick Craniofacial and maxillofacial
surgery in children and young adults, Vol. 1 and
Vol. 2.
9. Peterson, Ellis, Hupp, Tucker Contemporary oral
and maxillofacial surgery, 4th ed, 2006.
10. RA Cawson Essentials of dental surgery and
pathology, 5th ed.
11. Reynake, Evans, McCollum Introduction to
orthognathic surgery.
Fig. 18.39: Distraction osteogenesis 12. Turvey, Vig, Fonseca Facial clefts and
(For color version see plate 5) craniosynostosis, principles and management.
Neurogenic Disorders
of Maxillofacial Region
19
Definitions ii. Irradiation

iii. Compression neuropathies
1. Analgesia It is absence of pain in response
5. Tumors
to stimulation that would normally be
i. Benign and malignant.
painful.
2. Anesthesia It is absence of all sensation STUDY OF SOME
3. Neuralgia It is a condition of pain in the NEUROGENIC DISORDERS
distribution of a nerve or nerves.
4. Neuropathy It is disurbance of function I. Traumatic Injuries
or pathologic change in a nerve 1. Neurapraxia:
5. Paresthesia It is abnormal sensation, It is a physiologic paralysis of the conduction
whether spontaneous or evoked. of intact nerve fibres as a result of stretching
6. Paresis It is incomplete paralysis. or distortion without organic rupture.
CLASSIFICATION OF Causes
NEUROGENIC DISORDERS Bone fragments
Tourniquet
1. Traumatic injuries Plaster cast
i. Neurapraxia Postoperative.
ii. Axonotmesis
iii. Neurotmesis Features
iv. Traumatic neuroma Parasthesia
2. Inflammation Weakness of muscle
i. Neuritis
Treatment
3. Neuralgias
i. Trigeminal nerve neuralgia Self correcting condition
ii. Bell's palsy Splinting the limb in position of relaxation.
iii. Glossopharyngeal neuralgia 2. Axonotemesis:
iv. Sphenopalatine neuralgia It is the rupture of the nerve fibres
4. Special type of injuries (anatomical disruption of axon) within an
i. Infection injuries intact nerve sheath.
Neurogenic Disorders of Maxillofacial Region 231
Causes II. Trigeminal Neuralgia

Severe injuries It is also called as "Tic douloureux", Trifacial
Fracture segments neuralgia and Fothergill's disease. It is called as
"Tic douloureux" because of the twitching of the
Features facial muscles of the affected site during the
attacks.
Anesthesia
Trigeminal neuralgia is the neuralgia of the
Parasthesia
Vth cranial nerve (trigeminal nerve). There is
Weakness of muscle
specific painful flexion of the face characterized
Paralysis of muscle
by momentary or repeated paroxysmal attack
of pain in one or more divisions of the trigeminal
Treatment
nerve usually initiated by irritation of trigger zone.
Splinting of the limb. Trigeminal neuralgia is a sudden, usually
Care of the skin unilateral, severe, brief, stabbing, lancinating,
Maintain nutrition of the limb recurring pain in the distribution of one or more
Surgical exploration of the nerve branches of the trigeminal nerve.
The progress or regeneration is checked by:
Tinel's sign: Percussion with a hammer on Etiology
the course of the nerve, will produce tingling 1. Hypersensitivity of the trigeminal nucleus,
sensation if regeneration occurs. abnormal hyper excitability of nerve elements
3. Neurotmesis: of brainstem and thalamus disturbances.
It is the accidental division (can be partial or 2. Allergic reaction because of excessive
complete division) of the nerve fibres and accumulation of histamine
nerve sheath. 3. Pressure changes in the superficial petrosal
sinus or compression by tumor in the area.
Causes 4. Deficiency of inhibitor in CNS, GABA.
5. Circulatory insufficiency to the gasserian
During parotidectomy (facial nerve) ganglion
Sarcoma of limb (lower limb nerves) 6. Along with multiple sclerosis
Thyroidectomy (Recurrent laryngeal nerve) 7. Dental pathosis
Surgery at mandibular third molar (inferior
alveolar and lingual nerve) Clinical Features
Surgery at the region of mental nerve
(mental nerve) 1. Older females are mostly affected
There is a complete parasthesia of the area 2. Maxillary and mandibular division of the
nerve are mostly affected
affected.
3. Severe paroxysmal pain
4. Unilateral location
Treatment
5. Mild superficial stimulation provokes pain
Prevent infection, contamination and tension 6. Frequently pain free periods between attacks
at the area of injury. 7. No neurologic deficits
Surgical repair of the nerve. 8. No dentoalveolar cause found
9. Local anesthesia of trigger zone temporarily iv. Mid brain tractotomy

arrests pain. v. Medually tractotomy
vi. Intracranial nerve decompression.
Diagnosis
Peripheral nerve injection: Alcohol, hot water
1. Mainly done by the examination of the and LA injections can be given into maxillary
characteristic clinical features along with the and mandibular nerves. It is mostly given in
trigger zones. infraorbital nerve, inferior alveolar nerve and
2. CT Scan and MRI is done to diagnose the mental nerve.
postoperative causes, neuritis and vessel
compression. Nerve section and Avulsion: Also called as
3. Response of Tab. Carbamazepine - universal Peripheral neurectomy. This procedure is per-
response is seen in case of trigeminal neuralgia formed under general anesthesia and is indicated
and is not seen in case of any other pain. in patients where other complex surgeries are
contraindicated. It is done in infraorbital nerve,
Treatment inferior alveolar nerve, mental nerve and rarely
lingual nerve. The disadvantage is the occurance
Treatment is done by combination of medical of parasthesia or deep anesthesia of the area.
and surgical methods. Avulsion of nerve is done from soft tissue
1. Medical: and bone for better results. Minimum of 1 cm
a. Carbamazepine 100 mg t.i.d x 5 weeks. of the nerve should be removed and all the
(Drug of choice)
peripheral branches should be removed. Nerve
b. Phenitoin, sodium valproate, amitripty-
end is cauterized and foramen should be plugged
line, gabapentine, felbamata
by non-absorbable material.
c. Trichloroethylene
d. Morphine I.M Cryosurgery: It is a simple, easier and safer
e. Nicotinic acid procedure. Here cryotherapy probe at tempe-
f. Vitamin B12 rature cooler than -60C is applied on the
g. HCl administration concerned nerve. Cryo probe (N2O probe) is
h. Acupunture applied for 1-2 min. followed by 3 min rest and
i. Hypnosis this procedure is done for 3 times. The disadvan-
2. Surgical: (Interruption of pain pathway tage is that recurrence is faster
between the central and periphery).
a. Extra cranial methods:- Radiofrequency thermo coagulation: It is a
i. Alcohol blocks in peripheral nerve relatively newer, preferred and reliable treat-
ii. Hot water and local anesthetic injection ment. Radiofrequency that can destroy pain
iii. Nerve section and avulsion fibres are used and the pain fibres are destroyed.
iv. Electrosurgery Alcohol blockage in gasserian ganglion: Glycerol
v. Cryosurgery or absolute alcohol is used commonly which
vi. Radiotherapy (thermocoagulation) causes ganglion neurolysis by dehydration.
b. Intracranial methods:-
i. Alcohol blockage in gasserian ganglion Retrogasserian Rhizotomy: Here preganglionic
ii. Retrogasserian rhizotomy trigeminal sensory roots are sectioned between
iii. Radiofrequency thermogangliolysis the gasserian ganglion and point of entry into
(RFTG) at gasserian ganglion the pons. It is done when other procedures fail.
Neurogenic Disorders of Maxillofacial Region 233
Radiofrequency thermogangliolysis at gasserian

ganglion: This procedure is preferred as it can
be done in older patients and compromised
patients. It is a simple, accurate, faster and
cheaper process, it has low rate of recurrence
and avoids eye damage.
1-2, thermal lesioning at 60C - 70C for 30
second each are given for achieving result.
Tractotomy procedure: This procedure is rarely
done and here incision of descending trigeminal
nerve tract is done. Fig. 19.1: Appearance of a person
with bells palsy
Intracranial nerve decompression: This technique
is a newer one and here open craniotomy
approach is done. The arteries and nerves are
reached and separated by a sponge or Teflon
wool placed between them.
III. Bell's Palsy

It is an idiopathic paralysis of the VIIth cranial
nerve - facial nerve.
Etiology:
The etiology is unknown but it is thought to have
been caused by ischemia of nerve near the Fig. 19.2: Bell's sign
stylomastoid foramen resulting in edema of the
nerve, its compression in the bony canal and Treatment
finally paralysis
1. Medical -
Clinical Features i. Beclamethasone 0.5 mg.
ii. Vitamin B12 and other vitamins supple-
1. Middle aged females are mostly affected
ments.
2. Bell's sign = when patient closes eye, the eye
iii. Supportive care.
globe turns upwards and there is slight 2. Physiotherapy:-
movement of upper eyelid (Fig. 19.2). This is done to maintain muscle tone. It can
3. Altered lacrimal and salivary secretion be combined with muscle message and
4. Voluntary movements are affected, whereas electric muscle stimulation.
emotional movements are less affected. 3. Surgery:-
5. Dysfunctioning of the upper face, inability to i. Nerve decompression surgery
wrinkle and deviation of the angle of mouth ii. Nerve anastomoses
with saliva dribbling from mouth (Fig. 19.1). Reanimation of central end of hypoglossal
6. Mask like face, slurry speech and difficulty or spinal accessory nerve and distal end of
in eating and drinking facial nerve.
7. Food lodgment poor oral hygiene, injections iii. Nerve grafting done in case of neurons or
and halitosis. loss of nerve in a region.
IV. Glossopharyngeal Neuralgia FURTHER READING

It is a neuralgia of the IXth cranial nerve- 1. Welden E BellOrofacial pain, classification,
glossopharyngeal nerve. diagnosis and management.
2. Archer WHOral and maxillofacial surgery,
Features 5th ed. vol 2.
1. The cause is unknown, but thought to be 3. Peterson, Ellis, Hupp, TuckerContem-
mainly due to neural ischemia. porary oral and maxillofacial surgery, 4th
2. Occurs in middle aged people ed, 2006.
4. Gustava O KrugerTextbook of oral and
3. Pain and other features are similar to
trigeminal neuralgia.
5. Daniel M LaskinOral and maxillofacial
4. Trigger zones are present in the posterior surgery, The Biomedical and clinical basis
oropharynx and tonsillar fossa. These are for surgical practice, vol. 2.
triggered by simple acts of swallowing, 6. Seward, Harris Mc GowonKilley and
talking, yawning or coughing. Kays Outline of oral surgery, Part I, 2nd ed.
5. The conditions is treated by resection of 7. Mann CV Russell RCGBailey and Loves
extracranial or intracranial portion of nerve. short practice of surgery, 21st ed, 1992.
Fractures of the Jaw 20
Fracture is any breakage or discontinuity of a Lower Facial Skeleton

bone, tooth or any hard structure of body. It
This part is formed chiefly by the mandible.
can be complete or incomplete.
APPLIED ANATOMY
The facial skeleton is divided into upper third,
lower third and middle third.
Upper Facial Skeleton

This is formed chiefly of the frontal bone making
the superior orbital margin and orbital roof.
Craniofacial injuries rarely includes the fracture
of this part as due to the cushioning effect
protecting it. Fig. 20.1: The facial skeleton
Mid Facial Skeleton

This part is formed chiefly by the following
bones:
2 Maxilla
2 Zygomatic bones
2 Zygomatic process of the temporal bone
2 Palatine bones
2 Nasal bones
2 Lacrimal bones
Vomer
Ethmoid and its attached conchae
2 Inferior conchae g
Pterygoid plates of the sphenoid. (For color version see plate 5)
ETIOLOGY OF DENTOFACIAL 2. Lateral region: Fractures involving the

FRACTURE zygomatic bone, arch and maxilla
The various etiologies in order of frequency are: (Zygomatic complex) excluding the
i. Inter personal violence dento-alveolar component.
ii. Sporting injuries II. Fractures involving the occlusion:-
iii. Falls 1. Dentoalveolar
iv. Road traffic accidents 2. Subzygomatic:
v. Industrial trauma a. Lefort I (low level or Guerin)
b. Lefort II (Pyramidal)
TYPES OF FRACTURES 3. Suprazygomatic:
c. Lefort III (high level or craniofacial
Various classifications of middle third fractures:
edysfunction).
A. Lefort classification:
F. Comprehensive classification:
I. Lefort I 1. Dentoalveolar fractures.
II. Lefort II 2. Zygomatic complex fractures
III. Lefort III 3. Nasal complex fractures
B. Erich's classification: (as per direction of 4. Lefort I, Guerin or low level fractures.
fracture line) 5. Lefort II, Pyramidal or infrazygomatic
i. Horizontal fracture fractures.
ii. Pyramidal fracture 6. Lefort III or Suprazygomatic fractures.
iii. Transverse fracture 7. Craniofacial fractures.
C. Depending on relation of fracture line to
zygomatic bone: Various classifications of mandibular fracture:
i. Subzygomatic fracture A. Depending on type of fracture (general) -
ii. Suprazygomatic fracture (KRUGER)
D. Depending on level of fracture line:- 1. Simple/closed:- Fracture that does not
communicate with exterior. (Greenstick
i. Low level
fracture - special type of simple fracture).
ii. Middle level
2. Compound/open:- Fracture that
iii. High level
communicates with exterior. ( E.g.
E. Rowe and Williams classification:
Fracture involving tooth bearing portion).
I. Fractures not involving the occlusion:-
3. Comminuted:- Fracture in which bone is
1. Central region:
splinted or crushed into multiple pieces.
a. Fractures of the nasal bones and/ (E.g. gun shot wound, penetration
or nasal septum. wound)
i. Lateral nasal injuries. 4. Pathogenic:- Fracture caused in already
ii. Anterior nasal injuries. weakened mandible by some pathogenic
b. Fractures of the frontal process of cause. (E.g. Osteomyelitis, neoplasm)
the maxilla. 5. Impacted:- One fracture fragment driven
c. Fractures of types (a) and (b) which into other fragment (mainly of maxillary
extend into the ethnoid bone (naso- fracture).
ethmoid) 6. Greenstick fracture:- Cortex of bone
d. Fractures of types (a), (b) and (c) is fractured and other cortex is bend
which extend into the frontal bone (Seen in children because of high bone
(fronto- orbito-nasal dislocation) resiliency).
B. Depending on site of fracture (Fig. 20.3)

1. Dentoalveolar- 3 percent
2. Condylar- 16.8 percent
3. Coronoid
4. Ramus- 1.9 percent
5. Angle- 31.3 percent
6. Body (molar and premolar area)- 24.8
percent
7. Parasymphysis- 22.2 percent
8. Symphysis Fig. 20.4: Horizontal favourable fracture
Fig. 20.3 Fig. 20.5: Horizontal unfavourable fracture

C. Depending on cause
1. Direct violence
2. Indirect violence
3. Excessive muscular contraction.
D. Depending on treatment considerations
1. Unilateral
2. Bilateral
3. Multiple
4. Comminuted
E. According to direction of fracture and
favorability of treatment Fig. 20.6: Vertical favourable fracture
1. Horizontal favorable fracture. (fracture
line along alveolar margin, downward
and forward) (Fig. 20.4)
2. Horizontal unfavorable fracture (fracture
line along alveolar margin, downward
and backward) (Fig. 20.5)
3. Vertical favorable fracture. (fracture line
from buccal plate, moving backward and
lingually) (Fig. 20.6)
4. Vertical unfavorable fracture (fracture line
from buccal plate, moving forward and
lingually) (Fig. 20.7) Fig. 20.7: Vertical unfavourable fracture
Favorable fractures are those when the to pass through the frontal sinuses
muscular pull cannot displace the fractured parts with the shadow of the dense petrous
and in unfavorable fracture the muscle pull temporal bone lying just below the
displaces the parts. inferior orbital rim.
Condylar head mostly displaces medially and b. Lateral projection
forward under the influence of lateral ptrerygoid. ii. Middle third
Coronoid process mostly displaces upward a. Occipitomental: The patient is upright
and towards infratemporal fossa under the with the nose and chin in contact with
influence of temporalis muscle. the plate. The central beam is angled
Guardsman's fracture- fracture of symphisis at 10 or 30 above the horizontal,
and both condyle by fall on the mid-point which throws the shadow of the dense
of the chin. Commonly seen in epileptics and petrous bone below the projection of
elderly patients and in soldiers who faint in the maxillary sinuses.
parade. b. Water's view: The central beam passes
Bucket Handle fracture- fracture of edentulous along the line of the orbital floor with
mandible seen in elderly patients (Fig. 20.8). the shadow of the dense petrous
temporal bone overlapping the lower
quarter of the maxillary sinuses. It is
useful when there is an isolated orbital
floor fracture.
c. Lateral projection
d. Occlusal view of the maxillae
e. Periapical views of involved or
damaged teeth.
iii. Mandible:-
a. Postero-anterior projection (P.A)
b. Oblique lateral projection with the
tube angled at 30 to the lower jaw.
c. Rotated posterior-anterior projection.
d. Occlusal views of the mandible.
Fig. 20.8: Bucket handle fracture e. Periapical views of the involved or
damaged teeth.
GENERAL DIAGNOSIS
OF A JAW FRACTURE
Diagnosis is done by proper history taking,
examine the features and confirming by the
various imaging techniques.
The imaging techniques used are
1. Plain radiographs:
The following plain views of the facial bones
may be useful in diagnosis -
i. Upper third
a. Modified Caldwell projection: The Fig. 20.9: Radiographic view of
central beam is directed from behind mandibular body fracture
A. Airway maintenance:
Nonsurgical:
Patient positioned supine with head
sideways
Removal of blood clot, foreign body,
saliva, thick mucosa etc from
oropharynx (oropharygneal toilets)
done by bronchoscopy
Anterior traction of tongue
Fig. 20.10: Radiographic view of Position of soft palate.
mandibular right angle fracture
Surgical/Tracheostomy:
2. Computerized tomography: Because of the Done in following cases:
easy availability and precise diagnosis When prolonged artificial ventilation
nowadays CT scan is most widely used. is necessary (head and chest injury)
3. MRI GA administration procedure
4. Intraoral radiography (IOPAR): This is used Ensure safe postoperative recovery.
Injury to tongue and oropharynx
to demonstrate the relationship of the teeth
Severe hemorrhage to airway.
in the line of fracture.
Technique
The radiographic findings are helpful to
i. Patient is intubated before surgery
confirm;
ii. Patient in supine position with neck
The site of fracture extended
Direction and displacements of fragments. iii. Vertical incision from midline of neck
Condition of teeth adjoining the fracture to lower border of cricoid is made
line. (vertical) (Figs 20.11A and B) or
Severity of damage of bone. Transverse incision from two finger
The presence of anybony pathology below sternal notch is made (trans-
involving the fractured fragments like verse)
impacted tooth, cysts or neoplasm. Vertical method is done emergency is
faster but transverse method is better
GENERAL TREATMENT in cosmetic beauty.
OF A JAW FRACTURE iv. Skin and muscles are reflected and
veins are retracted to expose the
Basic Principles/Three Steps trachea (Fig. 20.11C and D).
in Management v. Four percent xylocaine is infiltrated
into trachea.
1. Preservation of life.
vi. Incision, suture and dressing are done
2. Maintenance of function.
3. Esthetic restoration. (Fig. 20.11E).
1. Preservation of life: Immediate assessment

and treatment of any life threatening injuries
is done by-
A. Airway maintenance
B. Bleeding control
C. Consciousness restoration and circulation
maintenance. (A) Membrane covering trachea is divided
(E) Tracheostomy tube in position
(B) Trachea is cut open
(C) Opening is enlarged
(F) Post operative view

Figs 20.11A to F: Tracheortomy procedure
C. Consciousness restoration and circulation

maintenance:
Consciousness maintenances depends on
its cause-
- Intracranial injury
- Hemorrhage shock
(D) Insertion of tracheostomy tube - Neurogenic shock.
2. Maintenance of function is done by:
Cricothyroidotomy/Crycothyrotomy is Following the basic principles of fracture
incision through the skin and cricothyroid management, basic reduction and occlusal
membrane for the relief of respiratory maintainence.
obstructions. This is done prior to or in place
3. Esthetic Restoration is achieved by plastic
of tracheostomy in case of emergency respiratory
surgeries and other esthetic surgeries.
obstruction.
B. Bleeding control is done by:
PRINCIPLES OF FRACTURE
- Compression of blood vessels
MANAGEMENT
- Dressing of the wound
- Ligation of the blood vessels or 1. Reduction
clamping. 2. Immobilization and Fixation
The principle/method for the treatment of

facial fracture to be followed in a specific case
depends on:
Fracture pattern
Skill of operator
Resources available
General medical conditions of patient
Presence of other injuries
Degree of infection
Associated soft tissue injury and loss.
1. Reduction:
It is bringing of the fractured fragments close
to each other and in the correct anatomic Fig. 20.12: Incisions for exposing orbito-zygomatic
and functional position. This can be done complex: (a) Coronal, (b) Preauricular, (c) Lateral
either by a closed/nonsurgical way or by a brow, (d) Supratarsal fold, (e) lateral canthus, (f)
Subciliary, (g) Midtarsal, (h) Transconjunctiva
open/surgical way as the condition demands.
i. Closed/Non surgical reduction:
Mostly done by occlusal maintainence. The
wear facets acts as an important clue for ii. Lateral orbital rim and body of zygoma:
the occlusion anterior or lateral open bite. - Lateral canthus
Temporary reduction is done in some cases - Extended preauricular
to postpone the surgical procedure till the - Coronal.
general health of the patient improves. iii. Inferior orbital rim and orbital floor:
Non- surgical reduction is done either by - Midtarsal
using specially designed forceps- Rowe's - Subcilliary
disimpaction forceps, in a rocking and - Transconjunctival
rotating movement or by using elastic Incisions for surgical exposure of medial
tractional forces or even manually. orbital wall, naso-ethmoidal complex and frontal
bone:
ii. Open/Surgical reduction:
i. Local
This is done in cases where closed reduction
is not effective. Various surgical approaches ii. Coronal
are followed to reach the site of fracture. Incisions for surgical exposure of mandible:
Incisions for surgical exposure of maxilla: i. Submandibular approach - Risdon's
i. Vestibular ii. Postramal approach - Hind's
ii. Palatal iii. Postauricular approach
iii. Mid - face degloving procedure. iv. Endural approach
Incisions for surgical exposure of orbito- v. Preauricular approach:
zygomatic complex (Fig. 20.12): - Digman's
i. Supero-lateral orbital rim: - Blair's
- Lateral eyebrow - Thoma's
- Supratarsal fold - Popowich's modification of Al-Kayat and
- Extended preauricular Bramley's
- Coronal vi. Hemicoronal approach
vii. Intraoral approach degloving incision. c. Miniplates

(For details see the chapter on tempero- d. Lag screws
mandibular joint) e. Resorbable plates and screws
Before reduction any teeth present in the 2. Intermaxillary fixation:
fracture line may require extraction. The a. Bonded brackets
indications for extraction are; b. Dental wiring
- Longitudinal fracture involving root. i. direct
- Dislocation/subluxation of teeth from ii. eyelet
socket. c. Arch bars (Winter, Jelenko, Erich type)
- Presence of periapical infection. d. Cap splints (used in children).
- Infected fracture line 3. Intermaxillary fixation with osteosynthesis:
- Acute pericoronitis a. Transosseous wiring
- Functionless teeth (third molar) b. Circumferential wiring and internal
- Advanced caries suspension
- Advanced periodontal disease c. External fixation
- Teeth in untreated fracture from more d. Transfixation with Kirschner wires.
than 3 days.
Reduction should be done from outside to 1. Osteosynthesis without intermaxillary
inside. The outer frame bones are reduced first fixation:
and the inner nasal bones at the last (Fig. 20.13). Most fractures can be fixed using either form
2. Immobilization: of plates, whereas lag screws can be used in
Immobilization is the process of fixation or oblique fracture fixation. Semirigid plates are
making the fractured fragments stay in their less effective as a small gap exists between
reduced, anatomical and functional position the bone ends and the primary callus
until healing occurs. formation is limited whereas in compression
Various methods of immobilization are: plates full strength bone healing takes place
1. Osteosynthesis without intermaxillary but precise reduction is different to achieve
fixation: using compression plates, as compression
a. Non-compression plates plates work on the principle of fracture
b. Compression plates treatment of weight bearing long bones.
Hence non-compression miniplates are the
best and mostly used for treatment of jaw
fractures.
Miniplates
Earlier used miniplates were cobalt - chronic
alloy metacarpal plates of upto 1 inch in length,
for fixing the jaw bone fractures. In recent times
stainless steel and titanium are used for the
construction of these miniplates. Miniplates can
be of compression and non-compression type,
Fig. 20.13: Frame of fracture reduction of which the non-compression type is the best
(Outer to inner) used (Figs 20.14A and B).
Fig. 20.14A: Miniplates Fig. 20.14B: Compression plates
Armamentorium needed for use of mini- Contraindications of use of Plates

plates: 1. Grossly displaced, extensively communited
a. Screw driver and heavily contaminated fractures.
b. Plate bending lever 2. Presence of pathological abnormalities in
c. Plate bending plier bone.
d. Plate modeling pliers 3. Patients in mixed dentition period.
e. Cutting shears
f. Screw holding forceps Lag Screws:- It is effective only in certain oblique
g. Plates of assorted sizes stored in a rack fractures of mandible. Two or more holes are
drilled in the outer cortex whose diameter are
Technique for use of Miniplates slightly larger than the threaded part of the screw.
The screws are tightened such that the head of
Intraoral, extraoral of combination the screw engages the outer plate and thus
approaches are done for the insertion of compressing the fractured segments (Fig. 20.15).
plates.
Monoaxial and precise holes are drilled slowly Resorbable plates and screws:- Materials like
onto the either side polylactidies are used to construct plates which
Plates are adapted along the ideal are strong and rigid, and can be absorbed within
osteosynthesis line by bending with modeling the body after causing complete bone healing.
pliers. These are mostly used in orthognathic and
Atleast two screws are fixed on either side craniofacial surgeries.
which holds the plate firmly in position.
Indications of use of Plates

1. In cases where intermaxillary wiring is
contraindicated
2. In patients who desire to reduce the period
of healing.
3. Complicated fracture with loss of bone
segment or where non-union or malunion
has occurred
4. Fractures associated with closed head injuries Fig. 20.15: Lag screw
2. Intermaxillary fixation intermaxillary connection without stripping

It is a process of immobilizing the jaw in case off all the fixations. Hence eyelet wiring is
of dentulous patients. Mostly used along with preferred.
some form of direct osteosynthesis. ii. Interdental eyelet wiring (Gilmer's wiring):-
Silver cap splints and bonded orthodontic 20-25 cm long wire is grasped with two artery
brackets were earlier used for intermaxillary forceps on either side and two turns are given
fixation whereas these days other methods are in the middle of the wire around a 3 mm
more common. diameter round barthus making an eyelet
with two free ends. The eyelet is fitted by
Dental Wiring pushing between two teeth and the free end
is held passing through the lingual and palatal
0.45 mm, soft stainless steel wire is best used
aspect of the teeth before twisting the free
after stretching by about 10 percent for various
ends. Similarly five eyelets are placed in the
dental wiring procedures (Fig. 20.16).
upper and five in the lower jaw. The free
ends of the eyelet are attached to each other
in a cross-branching manner thus achieving
a strong fixation (Fig. 20.18). In this method
a fracture can be tested by removing only
the tied wires.
Arch Bars: This is the most versatile method and

is useful in cases where there are insufficient
Fig. 20.16: Dental wiring suitable number of teeth for eyelet wiring. Various
prefabricated arch bars - winter, Jelenko, Erich
i. Direct wiring:-15 cm long wire is twisted or metal bar bend to confirm the dental arch
around a suitable tooth and then the free is cut to the required length and is held attached
ends are twisted together to produce 7.5- to the dental arch by a 0.45 mm soft stainless
10 cm long plated wire. Similarly wires steel wire around the teeth. This method thus
attached on other teeth which are further helps in intermaxillary fixation (Figs 20.19 and
twisted together to achieve a temporary 20.20).
intermaxillary fixations (Fig. 20.17). In this
method it is difficult to release the
Fig. 20.17: Direct wiring Fig. 20.18: Eyelet wiring
Fig. 20.19: Intramaxillary fixation
Fig. 20.21: Transosseous wiring
Fig. 20.20: Arch bar wiring
3. Intermaxillary fixation with osteosynthesis:

Transosseous wiring:
In this method holes are drilled in the bone
ends either side of the fracture line after which
a length of 0.45 mm soft stainless steel wire
is passed through the hole and across the
fracture. The free ends are twisted tightly and
the twisted ends are tucked into the nearest Fig. 20.22: Internal suspension
hole (Fig. 20.21).
Circumferential wiring and internal suspension:
3. Inferior orbital border-mandibular
Internal suspension works on the principle that
suspension.
we use some stable portion of the facial skeleton
4. Fronto-mandibular suspension.
above the line of fracture as an anchorage point
5. Piriform fossa-mandibular suspension.
for the suspension wires, which are connected
to circumferential wiring in lower canine region External fixation: Its principle is that rigid rods
or a lower arch bar (therefore, the fractured and universal joints are used to link the reduced
maxilla is sandwiched between mandible and maxilla to fixed part on frontal bone or cranium
base of skull) (Fig. 20.22). thus immobilizing them.
The various suspensions used are: Indications for external fixation:
1. Circumzygomatic suspension 1. In case of infected fracture line
2. Zygomatico-mandibular suspension 2. In case of extensively communited fracture
Fig. 20.23: Halo frame

Fig. 20.24: Box-frame
3. In case of pathological fracture with large
amount of bone loss TREATMENT OF EDENTULOUS
4. In case of bimaxillary fractures. PATIENTS
Some of the systems used are:
i. Halo frame/plaster head caps: It is a frame In edentulous patients the procedure of
that encircles the head and attaches to reduction and immobilization is the same except
skull by 4 pointed screw pins (Fig. 20.23). for the fact that generally these patients have
ii. Supraorbital pins: Here support is poor medical conditions so surgical procedures
achieved from 2 bone pins inserted into should be avoided or done under special care.
the supraorbital ridge. Because of the absence of teeth intermaxillary
iii. Box-frame: This is an extension of the fixation is not possible so the various methods
supraorbital pin. Here 2 more pins (total of immobilization followed are:-
4 in no) are inserted into the mandibular 1. Direct osteosynthesis
region (Fig. 20.24). a. Bone plates
iv. Adhesive plaster: This is placed under the b. Tranosseous wiring
chin and carried over the vertex so that c. Circumferential wiring
adequate support to the mandible can d. Tranfixation with Kirschner wires.
be provided. e. Fixation using cortico cancellous bone
v. Barrel bandage: It is applied two or three grafts.
times around the vertex and the lower 2. Indirect external skeletal fixation
jaw. This bandage is wrapped around the 3. Using gunning splints either alone or in
forehead and back of the head and combination with other methods.
retained with the help of safety pin or
adhesive plaster. Gunning Splint
vi. Elastic chin bandage is an effective and Gunning hand introduced splint for dentulous
comfortable form of bandage mouths for fractured mandible treatment. This
vii. Four- tailed bandage: it helps to support is modified and used for treatment of fractured
fractured mandible. edentulous mandible.
It is a modified denture with bite blocks in

molar region and space in anterior for feeding.
Immobilization is achieved by using gunning
splint by:
i. In completely edentulous patient, upper
splint is attached to maxilla by peralveolar
wiring and lower splint is attached to
mandible body by circumferential wiring.
ii. In single edentulous patients, fixation is
done by fixing splints to the specific jaw and
then intermaxillary fixation.
This splint is used mainly for treating simple
Fig. 20.25: Inward and downward
mandibular fracture in edentulous patient by
operators with less experience.
Limited use of this splint is because of:
i. Food stagnation is there, therefore smells
fowl.
ii. Candida induced stomatitis is common.
iii. Poor control over mobile fracture especially
when mandible is very thin.
SPECIFIC FRACTURES OF
DENTOFACIAL REGION
Dento-Alveolar Fractures
These are the injuries in which avulsion,
subluxation or fracture of teeth occurs in Fig. 20.26: Inward and posteriorly
association with the fracture of the alveolus. The
treatment of such fracture requires immediate
and special care so as to relieve the patient of iii. Inward and posteriorly displacement (Fig.
the pain and to preserve the dentition. Soft tissues 20.26)
like upper lip and tongue laceration should be iv. Outward displacement (Fig. 20.27)
taken care of. Avulsed tooth is treated by vertical v. Comminution of the complex as a whole
splinting of one or more teeth. (Fig. 20.28)
2. Fracture of zygomatic arch alone- not
Zygomatic Complex Fractures involving the orbit (Fig. 20.29).
i. Minimal or no displacement
Classification ii. 'V' type of fracture
iii. Comminuted fracture.
1. Fracture of body of zygomatic complex
involving the orbit:
Clinical Features
i. Minimal or no displacement
ii. Inward and downward displacement (Fig. Flattening of cheek (seen immediately after
20.25) fracture or after edema has subsided)
alveolar nerves), temple (because of damage

to infraorbital and zygomatic nerve), upper
teeth and gingiva.
Periorbital hematoma
Subconjunctional hemorrhage
Tenderness over orbital rim and fronto-
zygomatic suture
Step deformation of infraorbital margin
Separation of frontozygomatic suture
Ecchymosis and tenderness intraorally over
zygomatic buttress.
Limitation of ocular movement
Fig. 20.27: Outward Diplopia
Enophthalmos
Lowering of the pupil level
Epistaxis
Limitation of mandibular movement
(because of impingement of the coronoid
process)
Possible gagging of back teeth on injured
side
If only zygomatic arch is fractured then the
main features are:
Limited mandibular movement
Depression of check and edema.
Fig. 20.28: Comminution
Radiographically; zygomatic fracture is
diagnosis with the help of occipitomental
projection.
Treatment
In cases of minimal fracture of zygoma and in
cases where patient is very elderly and has more
postoperative risks, open reduction or any
surgical procedures to treat zygoma fracture is
contraindicated.
Indication for zygoma fracture reduction:
1. To restore normal contour of face (due to
Fig. 20.29: Zygomatic arch alone cosmetic reasons and for estabilishing facial
skeletal protection of orbit)
2. To correct diplasia
Swelling of cheek 3. To remove interference in mandibular
Anesthesia of cheek, (because of damage to movement
anterior, middle and posterior superior 4. To decompress nerves.
Reduction ii. Percutaneous Approach: Here many

hook ended instrument are used to
Many zygomatic complex fractures are stable
reduce zygomatic bone fracture in cases
after reduction and does not need any fixation,
where there is medial or lateral displace-
e.g.: mesial/lateral displacement of zygoma along
ment with no separation in frontozygo-
vertical axis without separation of frantozygo-
matic suture. There is a single fine suture
matic suture.
and thus the wound is almost invisible.
Various methods of reduction are:
iii. Intraoral Approach: This procedure is not
i. Temporal Approach (Gille's Approach):
widely practiced. In this approach incision
Principles of Gille's Approach: Zygomatic
is made at the upper buccal sulcus behind
arch is covered by temporal fascia in
zygomatic buttress and curved elevator
superior surface and has temporal muscles
is passed to engage deeper surface of
attached beneath. Thus if an incision is
zygomatic bone, thus reducing it.
made along the hairline and through the
temporal fascia, the instrument (Rowe's
Fixation
zygomatic elevator) can pass down till the
temporal muscle beneath the zygomatic Fixation can be achieved in following ways:
arch, thus enabling the zygomatic bone to i. Temporal support: It is done as an alternative
be elevated into correct position (Figs 20.30 to open reduction when the reduced
and 20.31). zygomatic complex is unstable. Materials
used in this procedure are:
Procedure - Antral packs
- Balloon catheters in antrum
An oblique 2 cm incision is made at the hairline
ii. Direct fixation:
between the bifurcations of the superficial
a. Transosseous wiring (of frontozygomatic
temporal vessels, the temporal fascia is exposed
suture): It is the best method used if plates
and using a Rowe's/Bristow's elevator the
are not available. Holes are drilled in the
zygomatic bone is brought back to position.
Fig. 20.31: Clinical view of the procedure of Gilles

Fig. 20.30: Gilles approach approach for zygomatic complex fracture reduction
zygomatic process of frontal bone and Treatment

frontal process of zygomatic bone. Treatment is aimed at achieving proper shape
Stainless steel wire is passed through the of nose and maintaining the proper functional
holes and twisted. To increase stability nasal passage.
figure of '8' wire is used. In most of the nasal fractures, there is a slight
b. Bone plates: This is the best used method, fracture of the nasal bone and closed reduction
especially for unstable fracture. Materials using Ash's septal forceps and Walsham's forcep.
available are:- Only in severe cases of naso-ethmoidal fractures,
Vitallium miniplates open reduction is done. Immobilization is rarely
Stainless steel plates required, only in case where complete displace-
Titanium plates (relatively more ment is there. Immobilization is achieved by
biocompatible) using intraoral or extranasal splintage.
Microplates
Mesh and special grid design plates Lefort - I Fracture
Resorbable materials
iii. Indirect Fixation: In this method, the (Subzygomatic fracture, low level fracture,
zygomatic bone is fixed indirectly to other horizontal fracture or Guerin's fracture)
parts of facial skeleton while healing takes Here the fracture is such that the body of
place. This method is of limited use in case maxilla is separated from the base of skull above
of unstable fracture. Materials used are: the level of palate and below the attachment
Rigid rods (used extraorally) of zygomatic process. The fracture line extends
Transantral internal pins. backwards from lateral margin of the anterior
nasal aperture below zygomatic buttress to cross
Nasoethmoidal Fractures the lower third of pterygoid plate (Fig. 20.32
and 20.33).
Features
Fracture of naso-ethmoided complex may
involve the nasal, frontal, ethmoidal, frontal
process of maxilla, lachrymal bones and
septal and vomer.
Brushing of skin over nasal bone
Laceration of skin of bridge of nose
Bilateral medial orbital ecchymosis
Epistaxis
Deformity of nose
Cripitus of bones of nasal complex
Unilateral or bilateral telecanthus
Airway obstruction
Septal laceration and hematoma
Cerebrospinal rhinorrhea Fig. 20.32: Lefort-I fracture line
Septal deviation. (For color version see plate 7)
wards and backwards across the lateral wall of

the antrum below the zygomatico- maxillary
suture and divides the pterygoid plate about half
way (Figs 20.34 and 20.35).
Features
Gross edema of middle third of face -
"Ballooning of face" or "moon face".
Bilateral circumorbital edema and ecchymosis
"Black eye".
Bilateral subconjunctival hemorrhage
Fig. 20.33: Lefort-I fracture "Flat face" - depressed nose.
Features
Swelling and edema of lower part of face.
Ecchymosis of lingual and labial vestibule
Mobility of the upper dentoalveolar portion-
Floating jaw.
Involvement of the teeth, lip and cheek may
be seen.
Occlusion derangement may/may not be
there.
On percussion of the maxilla at the molar
and premolar region - a characteristic
"Cracked Cup" or "Pot" sound is heard.
Impacted or "Telescopic fracture" may be
there. (the displaced fragment, moves Fig. 20.34: Lefort-II fracture line
upwards and gets locked). (For color version see plate 7)
Bilateral epistaxis or nasal bleeding is seen.
Ecchymosis in region of greater palatine
foramen- Guerin's sign.
Lefort - II Fracture
(Pyramidal fracture, subzygomatic fracture,
vertical fracture):
It is a vertical fracture extends upwards to
the nasal and ethmoid bones, usually through
maxillary sinus and one malar bone is involved.
The fracture line extends from midline of
nasal bone down either side crossing the frontal
process of the maxilla into the medial wall of
each orbit. Then the fracture extends down- Fig. 20.35: Lefort-II fracture
Anterior open bite and other occlusal

dearrangement
Bilateral epistaxis (bleeding from nose)
Difficulty in mastication and speech
Surgical emphysema
CSF rhinnorea
Step deformation at the infraorbital margin
felt on palpation
Anestheia and paresthesia of cheek due to
involvement of infraorbital foramina.
Airway obstruction caused due to the
impinging of the displaced fragments in the
dorsum of tongue
Radiographic diagnosis is difficult due to
overlapping of the fragments. Fig. 20.36: Lefort-III fracture line
Lefort - III Fracture
(High level fracture, Transverse fracture, cranio-
facial separation)
It is a transverse fracture where there is
complete separation of midface at level of
nasoorbital-ethmoidal complex (NOE-complex)
and zygomaticofacial suture area. Fracture also
extends through orbit bilaterally. The fracture
line extends across the orbit through the base
of nose and ethmoidal region to the zygomatic
arch (Figs 20.36 and 20.37).
Features
Fig. 20.37: Lefort-III fracture line
Features are similar to those seen in lefort
II fracture but are of more severe and intense
nature.
percent chance of death, if two orbits are
Gross edema of middle face (ballooning)
involved then 95 percent chance of death.
Bilateral circumorbital ecchymosis and edema
Bleeding from ears and nose (Epistaxis)
(prevents opening of eye)
On palpation, bony step felt in infraorbital
Bilateral subconjunctival hemorrhage.
area
"Dish face" - central portion of the face is
CSF leak (neurologic involvement)
dished in
Spooned out appearance in nasal area
General Features in Lefort Fractures
(because of fractured and posterior dislo-
cation of maxilla) i. Airway obstruction: Excess bleeding, foreign
CSF rhinorrhea and orbital signs indicates body obstruction (tooth, denture) can cause
cranial fracture and neurologic involvement, airway obstruction. It occurs even when soft
generally if one orbit is involved then 50 palate and tongue are pushed back.
Fig. 20.38: Clinical view of a patient with Lefort facial fracture. Epistaxis, CSF Rhinorrhea, facial edema,
circumorbital ecchymosis, subconjunctival hemorrhage, facial disfigurement, orbital sign, etc are seen (For
color version see plate 8)
ii. Epistaxis: Bleeding from nose. v. Emphysema: Air can be ingested in soft
iii. CSF Rhinorrhea: It is seen mainly in LeFort tissue and specially due to tear in perio-
II and III fracture, due to dural tear asso- steum and sinus lining and is felt as crepitus
ciated with fracture of cribriform plate of on palpation.
ethmoid. It generally gets arrested in few vi. Circumorbital ecchymosis (Black eye)
days either spontaneously or after reduction vii. Subconjunctival hemorrhage
and fixation of fracture. It may lead to viii. Occlusal disturbance (anterior open bite and
meningitis, so needs prophylactic antibiotics premature contact of molars are present if
and neurosurgeon care. fracture involves dentition).
Diagnosed by: (different to detect imme- ix. Facial disfigurement: Elongation of face,
diately as gets mixed with blood) saddle and flat nose, dish -shaped face and
Tran line pattern seen on face flattened cheek is seen.
Halo effect on pillow and sheet (It x. Abnormal opening of mouth: It occurs due
appears because of clear CSF spreading to downward displacement of fractured
beyond clotted blood component) middle third or due to zygomatic bone
In order to distinguish from mucous flow, fracture.
CSF does not starch handkerchief on xi. Orbital symptoms: These include limited
drying. opening of eye, enophthalmos, diplopia,
It can also be diagnosed by: blindness or decreased vision.
Test for protein and glucose xii. Oronasal opening: It is seen in case of palatal
C.T scan fracture.
Intracranial administration of
radioisotope and detection in Orbital Floor Fracture
nasopharynx and stomach It is also termed as blow out fractures. It can
MRI is the confirmatory test. be classified as:
iv. Facial edema: Here ballooning of the face 1. Impure blow out fracture (it includes LeFort
takes place and in severe cases, eyes cannot II and III fractures or other fracture involving
be opened. orbital floor).
2. Pure blow out fracture (it includes isolated II. 1. Mono-ocular (here diplopia is on one eye
orbital floor fracture) (Fig. 20.39). and severe ocular cause is present which
It is called as "Blow-out fracture" as it needs attention)
describes mechanism of injury i.e. here there 2. Bin-ocular (diplopia effects both eyes
is posterior displacement of globe of eye by because of zygomatic fracture).
blunt trauma (deformation of infraorbital rim Limited eye movement
and rupture of orbital floor). Globe retraction
Enophthalmos (inward sinking of eye)
Features Emphysema of eyelid
Parasthesia in the area of distribution
Periorbital ecchymosis
of infraorbital nerve
Subconjunctival hemorrhage
Herniation of orbital fats into maxillary
Diplopia (double vision or blurred vision).
sinus.
It is caused due to interference with the
action of extraocular muscles causing
Diagnosis
oedema and haemorrhage in and around
these muscles. Clinical features (hanging drop appearance
If there is actual damage to the extraocular Posterioanterior view (radiograph)
muscles (not mere interference, then there Water's projection (radiograph)
is permanent diplopia) or to there nerve CT scan
supply.
Treatment
Types of Diplopia
Surgically exploring orbital floor and
I. 1. Temporary (interference with the muscles) reconstructing orbital floor by sheet or bone
2. Permanent (damage to muscles or nerve graft is necessary
supply). Balloon support and ribbon gauge
packing in sinus done for treating orbital
floor fracture.
Mandibular Fractures
Features
The features of mandibular fracture are
determined by the location of the fracture line
and the intensity of the fracture.
I. Condylar Fracture
Classifications
A. Row and Killey's classification, depending on
the location.
1. Extracapsular fracture/low condylar
fracture/subcondylar fracture: Here,
Fig. 20.39: Herniation of periorbital fracture runs from lowest point of sigmoid
fat due to fracture notch till upper part of ramus.
2. Intracapsular fracture/high condylar

fracture: Here, fracture may or may not
involve articulating surface but is above
the neck of the mandible.
3. Fracture involving ligament and capsule.
4. Fracture involving adjacent bone.
B. Mac Lennan's classification depending on the
features:
1. No displacement: Crack fracture is seen
but no alteration to relationship between
Fig. 20.42: Displacement
condylar head and glenoid fossa or neck
of condyle and ramus (Fig. 20.40).
2. Deviation: Simple angulations between
condylar neck and ramus (Fig. 20.41).
3. Displacement: Overlap between condylar
neck and ramus, condylar lie lateral to
ramus (Fig. 20.42)
4. Dislocation: Disruption between condylar
head and glenoid fossa, condylar
fragment pulled by lateral pterygoid
muscle (Fig. 20.43).
Fig. 20.43: Dislocation
Features
Evidence of facial trauma seen.
Localized pain and swelling TMJ
Deviation of mandible upon opening
towards the involved side in unilateral
fracture.
Posterior dental open bite on the contralateral
side in unilateral fracture
Fig. 20.40: No displacement
Limited opening of mouth
Difficulty in lateral and forward movement
of mandible
Blood in external auditory canal (epistaxis)
Shift of dental occlusion
Pain on palpation over the fractured site
Lack of condylar movement
Anterior open bite in case of bilateral fractures
CSF back through ear due to fracture of
middle cranial fossa.
Abnormal mandibular development and
Fig. 20.41: Deviation ankylosis of jaws is seen in cases where
treatment is delayed, especially in case of Anestheisa and parasthesia of lower lip of

condylar fracture in growing children. fractured side.
Battle's sign- Hematoma is found surrounding Tender on palpation near angle.
a fractured condyle which may track Movement or crepitus at fractured site on
downwards and backwards below the palpation.
external auditory canal, which gives rise to In case of unfavorable fracture of angle of
ecchymosis of the skin just below the mastoid mandible the line of treatment is open
process (also seen in fracture of the base of reduction with miniplates and screws.
the skull)
V. Body Fracture
II. Coronoid Fracture
(Molar and premolar region)
Coronoid fracture of the mandible is a very rare
fracture. Features
Features Swelling at site
Pain while movement
Difficult to diagnose clinically Occlusal disturbance
Tenderness over anterior part of ramus
Intraoral hemorrhage
Tell-tale haematoma
Anesthesia and parasthesia in distribution of
Painful limited mandibular movement.
inferior alveolar nerve (lower lip).
III. Ramus Fracture
VI. Parasymphisis and
Ramus fracture is also a rare fracture. Symphisis Fracture
Features This type of fracture is usually associated with
condylar fracture.
Swelling present intraorally and extraorally
Ecchymosis present both intraorally and Features
extraorally
Tenderness over ramus Loss of voluntary tongue control and airway
Pain while mandibular movement obstruction.
Trismus Disorientation of anterior mandible and
adjacent soft tissues.
IV. Angle Fracture
SPECIFIC FEATURES IN TREATMENT
Features OF MANDIBULAR FRACTURE
Painful mandibular movement The treatment of mandibular fracture in
Trimus children before puberty is generally of a
Swelling at angle and therefore facial conservative nature because of the rapidity
asymmetry of healing and adaptive potential of the bone
Step deformation behind last molar when and its contained dentition.
seen intraorally In the very young with unerupted or very
Occlusal disturbances few deciduous teeth, use of an overall gunn-
Adenotoma at angle of mandible ing splint for the lower jaw is recommended.
Cap splint can be constructed for mixed ii. Delayed union: Caused of delayed union:
dentition. Infection
When there are sufficient firm erupted Old age
deciduous and permanent teeth, eyelet wiring Nutritional deficiency
or arch bars can be used. iii. Nonunion (eburnation)
Bone plates and pins are contraindicated in Caused of nonunion:
most cases of mandibular fractures in patients Infections
Improper immobilization
less than 10 years. Only in case of gross
Inadequate approximation
displacement of symphysis or angle fracture, Ultra thin, edentulous mandible
the lower border may be wired. Excess loss of bone and soft tissue
COMPLICATIONS OF Inadequate blood supply
Bony pathology like tumor
FRACTURE TREATMENT
General systemic diseases
1. During Treatment Sequestration of bone
i. Infection: Seen more in diabetic patients or Scar formation in the region.
patients with reduced immunity, steroid
therapy. FURTHER READING
ii. Nerve injury: Damage to inferior alveolar 1. Archer WHOral and maxillofacial
nerve or facial nerve leading to anesthesia Surgery, 5th ed, vol. 2.
of lower lip, face etc. 2. Banks, BrownFracture of the facial
iii. Displaced teeth and foreign body being skeleton.
aspirated. 3. David/SimpsonCraniofacial trauma.
iv. Pulpitis, gingival and periodontal compli-
4. FonsecaOral and maxillofacial trauma,
cations.
Vol. 1 and Vol. 2, 3rd ed.
2. After Treatment 5. Geoffrey L HoweMinor and Surgery, 3rd
i. Malunion:- ed.
a. Dysarthrosis - Morphological changes in 6. OmarAbubaker, Keneth BensonOral and
unreduced dislocated fragments leading Maxillofacial Surgery secrets, 2nd ed.
to limited movement and pain. 7. Peter BanksKilleys fracture of the
b. Metaarthrosis - Anatomically altered but mandible, 4th ed.
functionally accepted union leading to no 8. Peterson, Ellis, Hupp, TuckerContempo-
severe symptoms. rary oral and maxillofacial Surgery, 4th ed,
c. Pseudoarthrosis - False joint leading to 2006.
severe pain during movement. This is 9. Ranajit SenFractures of the mandible.
caused due to formation of cartilaginous 10. RA CawsonEssentials of Dental Surgery
tissues over fractured bone and with a and Pathology, 5th ed.
cavity in between, containing clear fluid. 11. Ward Booth, Eppley, Schmelzeisen
This is notably seen in old fractures. Maxillofacial trauma and esthetic facial
Causes of malunion: reconstruction.
Improper fixation 12. Ward Booth, Schendel, Hausamen
Early mobilization Maxillofacial Surgery, 2nd ed, Vol. 1 and
Tissue entrapment Vol 2.
UNIT V
APPENDICES
Appendix 1
(Osteology)
OSTEOLOGY
Osteology is the study of bones. The skeleton of the
head is called as the skull. The skull is made up
of two parts - the calvaria is the upper part of the
cranium which encloses the brain and the facial
skeleton that includes the rest of the skull and include
the mandible.
The skull consists of 22 bones and divided into:
i. The clavaria, composed of 8 bones, they are:
i. Paired ii. Unpaired
1. Parietal 1. Frontal
2. Temporal 2. Occipital
3. Sphenoid
4. Ethmoid
ii. The facial skeleton is composed of 14 bones,
they are:-
Paired Unpaired
1. Maxilla 1. Mandible Bones of The Skull
2. Zygomatic 2. Vomer. (For color version see plate 8)
3. Nasal
4. Lacrimal
5. Palatine
6. Inferior nasal concha.
STUDY OF DIFFERENT 1. Norma frontalis

ASPECTS OF THE SKULL 2. Norma occipatalis
3. Norma lateralis
The skull is divided into five normas to aid in its 4. Norma basalis
study: 5. Norma verticalis
VARIOUS PARTS OF THE NORMAS
Norma frontalis
Norma occipitalis
Appendix1 263
Norma lateralis
Norma basalis
5. Stylomastoid foramen
Facial nerve
Stylomastoid artery
6. Carotid canal
Internal carotid artery.
7. Jugular foramen
Posterior compartment: internal jugular vein
Middle compartment: glossopharyngeal,
vagus and accessory nerves.
Anterior compartment: inferior petrosal sinus.
8. Foramen Lacerum
Internal carotid artery across cerebral surface
of fibro cartilage.
Norma verticalis 9. Foramen Magnum
Spinal cord
Meningeal coverings
Spinal accessory nerve
Vertebral arteries
Anterior spinal artery
Posterior spinal arteries.
FORMAINA'S OF THE SKULL Ligaments.
AND CONTENTS OF EACH 10. Hypoglossal canal
Hypoglossal nerve.
1. Superior orbital fissure 11. Condylar canal
Oculomotor nerve Emissary vein
Trochlear nerve 12. Foramen rotundum
Ophthalmic division of trigeminal nerve Maxillary division of trigeminal nerve.
Abduceus nerve 13. Mandibular foramen
Sympathetic fibres from cavernous plexus Inferior alveolar vein
Ophthalmic vein. Inferior alveolar artery
2. Inferior orbital fissure: Inferior alveolar nerve.
Infraorbital nerve
Infraorbital artery
DEVELOPMENT OF MANDIBLE
Orbital branch of maxillary division of
trigeminal nerve The mandible is the second bone (next to the clavicle)
Zygomatic branch of maxillary division of to ossify in the body. A greater part of the mandible
trigeminal nerve ossifies in the membrane whereas the part that ossifies
3. Foramen ovale in the cartilage are the incisive part below the incisor
Mandibular division of trigeminal nerve teeth, the condylar, coronoid process and the upper
Accessory meningeal artery half of the ramus above the level of mandibular
4. Foramen spinosum foramen. The mandible starts ossifying at 6th week
Middle meningeal vessels of intrauterine life in the mesenchymal sheath of the
Meningeal branch of mandibular nerve. Meckel's cartilage.
Appendix 2
(Case History)
A GENERAL CASE HISTORY FORMAT Dental Examination

USED IN ORAL AND MAXILLOFACIAL
Extra- oral:
SURGERY
Lymph nodes -
TMJ findings -
Personal Details
Intra-oral:
Name - Address -
Age - Occupation - Soft Tissue Examination
Sex - Religion - Gingival -
Chief Complaint - Colour -
History Of Present Illness - Contour -
Past Medical History - Consistency -
Past Dental History - Shape -
Drug History - Size -
Family History - Surface texture -
Personal History - Bleeding on probing -
Position -
General Examination Examination on pressure -
Hard Tissue Examination

Physical Examination: Examination of vital signs:
Nourishment- Blood pressure- Teeth present -
Built - Pulse - Missing teeth -
Gait - Temperature - Carious teeth -
Filled teeth -
Root stumps -
Clinical Examination
Mobile teeth -
Pedal oedema- Tender on percussion -
Clubbing - Provisional Diagnosis
Pallor -
Ecchymosis - Investigation:-
Cyanosis - Radiological -
Biochemical -
Jaundice -
Histopathological -
Petechiae -
Final Diagnosis:-
Any others -
Treatment Plan:-
Treatnent Done:-
Drugs Prescribed:-
Appendix 3
(Armamentarium)
ARMAMENTARIUM USED IN ORAL AND VIII. Instruments for bone removal:

MAXILLOFACIAL SURGERY 1. Bone rougeurs
2. Chisel
I. Instrument for anesthesia, airway maintenance: 3. Osteotome
1. Laryngoscope 4. Gigli's saw
2. Endotracheal tube 5. Bone file
3. Cricothyrotomy set 6. Hand piece and bur.
4. Tracheostomy set IX. Instruments to hold the bone:
II. Instrument for gaining surgical asepsis: 1. Bone holding forceps
1. Cheatlc forceps 2. Sequestrum holding forceps
2. Swab holder X . Instrument for wound debridement:
3. Tower clip 1. Curette
III. Instrument for gaining access: 2. Bone scoop
1. Scalpel 3. Listers sinus forcep
- Blade handle 4. Drains
- Blade XI. Instrument for management of fracture
2. Dissecting scissors osteotomies:
IV. Instruments for reflection of mucoperiosteal 1. Hayton Williams forceps
flap: 2. Rowe's disimpaction forceps
1. Periosteal elevator. 3. Walsham forceps
V. Instruments for retraction: 4. Asche's forcep.
1. Langenback 5. Bone awl
2. C-shaped 6. Rowe's zygomatic elevator
3. Austin 7. Wire pusher
4. Cat's paw retractor 8. Smith's bone spreader
5. Obwegessor's 9. Nasal speculum.
6. Skin hook XII. Miscellaneous instrument:
7. Chin 1. Mouth prop
8. Alar 2. Mouth gag
9. Tongue depressor. 3. Foleys self retaining catheter
VI. Instruments for suction: 4. Ryle's tube
1. Suction tube 5. Jaw stretcher
2. Suction tip 6. Trocar
VII. Instruments for holding: 7. Surgical diathermy
1. Needle holder 8. Cryosurgery
2. Hemostatic forceps 9. Infant feeding tube
3. Kocher's artery forceps
4. Tissue holding forceps
a. Alli's tissue holding forceps
b. Adson's tissue holding forceps
Appendix3 267
Old Days Dental Armamentarium Modern Days Dental Armamentarium
Dental Armamentarium
Appendix 4
(Facial Pain)
CLINICAL FEATURES OF SOME IMPORTANT
LOCAL CONDITIONS CAUSING FACIAL PAIN
Pain due to Character Site of pain Radiates Precipitating Relieving Timing Other Progress if
of pain into factors factors symptoms untreated
and signs
1. Pulpal Sharp and Affected Ear (lower Intra oral Withdrawal Occurs only Caries of May progress
cases severe at tooth and/or teeth) thermal and of stimulus stimulus crown of to acute
first. Later referred to and cheek, osmotic (stage 1). applied tooth. New periodontitis
s h a r p , another eye and changes at Mild (stage I). restoration and abscess
severe and tooth or temple first. Later, analgesics Lasts 20-30 fracture of formation.
continuous. edentulous (upper nil. at first but min after or crack in
area in teeth) analgesics stimulus enamel.
either jaw or gradually withdrawn
same side of lose effect. (stage 2).
face. Usually lasts
longer than
30 min
(stage 3)
2. Acute Dull at first. Affected ------- At first nil but Biting on Continuous Redness of May progress
Periodontitis Later dull tooth. later biting affected but worse at overlying to abscess
with acute on tooth. tooth in mealtimes. gum. formation.
exacerbations early stages Affected
when tooth only tooth 'high'
bitten upon. Analgesics to bite and
periodontitis.
3. Acute Dull, Affected Ear (lower Biting upon Heat in Continuous W h e n Pus bruits into
dental throbbing tooth. tooth), or touching early stages. worse at swelling soft tissues
abscess and severe cheek, eye i n v o l v e d Analgesics night and appears and pain
with sharp and temple touch. mealtimes. after few diminishes.
exacerbations (upper Prevents hours pain is Pus may
when tooth). sleep. less intense discharge and
involved although lesion may
tooth involved b e c o m e
bitten tooth is still chronic.
upon or acutely
touched. tender to
t o u c h .
Te n d e r
lymph nodes
and pitting
edema.
Contd...
Appendix4 269
Contd...
Pain due to Character Site of pain Radiates Precipitating Relieving Timing Other Progress if
of pain into factors factors symptoms untreated
and signs
4. Acute Dull and Affected To the ear Impinging Local Continuous Pyrexia, Infection may
pericoronitis continuous. area. Lower on upper application worse at swelling, either resolve
Closure of third molar occasions. molars. of heat. mealtimes. trismus, bad or spread or
jaws regions are Inability to Analgesics Seldom taste, foetor, become
increases the most clean area prevents dysphasia, chronic.
pain if common efficiently. sleep. tender lymph
impinging site. Upper nodes
tooth is respiratory
present. infection.
5. Dry Dull, Site of an To the ear Touching Local Continuous Foetor oris. May resolve in
socket throbbing, extraction when affected application worse at Involved about 2 weeks
continuous performed lesion in area. of heat. mealtimes. bone is ten- or progress to
ache. 2-4 days lower jaw. Analgesics May der. Socket sequestration.
previously prevent contains
sleep. broken
down blood
clot.
6. Acute Dull, Infraorbital Eye and Jolting and Decongestant Continuous Previous May become
maxillary throbbing, part of cheek temple on bending nose drops and may 'cold in head' chronic and
sinusitis. and and related the forwards analgesics prevent pyrexia. cause chronic
continuous. upper teeth. affected sleep. Feeling discharge.
Rarely occurs side. fullness in
bilaterally. cheek.
Nostrils
blocked.
Related teeth
tender to
percussion.
Tender on
infraorbital
pressure may
complain of
post nasal
discharge.
Enlarged
tender lymph
nodes.
7. Acute Dull, Affected May cross Patient Analgesics Continuous Mild pyrexia, Becomes
ulcerative continuous areas of midline if generally but seldom foetor oris, chronic and
gingivitis. pain. mouth. affected runs down. prevents bleeding destroys
Touching areas do. Poor oral sleep. gums. supporting
lesions hygiene. Unpleasant tissues of teeth.
causes taste, tender
severe lymph
pain. nodes,
trismus,
malaise.
Appendix 5
(Facial Swelling)
DECISION TREE FOR FACIAL SWELLING
Appendix 6
(White Lesions)
DIAGNOSIS OF WHITE LESION

OF ORAL MUCOSA
DIFFERENTIAL DIAGNOSIS OF ORAL WHITE LESIONS
Appendix 7
(Inability to Open Mouth)
CAUSES OF INABILITY TO OPEN MOUTH 4. others: Due to myositis ossificans or

submucous fibrosis.
Inability to open the mouth is caused due to many
III. False Ankylosis: This is Ankylosis of the TMJ
reasons as follows:
caused due to extracapsular causes. It is caused
I. Trismus: Which is muscle spasm caused due
due to:
to:
1. Infective causes:
1. Odontogenic cause:
- Periarticular suppurations.
- Infective (Periodontitis, pericoronitis, space
2. Traumatic cause:-
infections, parotitis)
- Periarticular fibrosis
- MPDS (Myofacial pain dysfunction
- Dislocation of longer duration.
syndrome) which is due to eruption of teeth
3. Neoplastic cause:-
or traumatic occlusion.
- Neoplasm of the periarticular tissues.
2. Traumatic cause:
4. Others:-
- Fractured teeth and jaw bones.
- Periarticular fibrosis following radition.
3. Neoplastic cause:
IV. True Ankylosis: This is ankylosis of the TMJ
- due to tumours eroding the muscles of
due to intra-articular causes. It is caused due
mastication.
to:
4. Neurotoxic cause:
1. Infective cause:
- due to tetanus.
- Regional spread of infection from middle
5. Psychogenic cause:
ear (otitis media) and osteomyelitis of the
- due to hysteria.
mandible.
6. Pharmacological reason:
- Hematogenous spread.
- due to phenothiazine group of drugs.
2. Traumatic cause:
II. Pseudo-Ankylosis: This is a mechanical
- Intracapsular fracture resulting in
interference in the temperomandibular joint
hemarthrosis.
caused due to:
- Penetrating wounds into the joint.
1. Traumatic cause: Depressed fracture of the
- Birth injury during forcep delivery.
zygomatic arch resulting in the mechanical
3. Systemic cause:
obstruction to the coronoid process.
- Juvenile arthritis
2. Hyperplastic cause: Hyperplasia of the
- Rheumatoid arthritis
coronoid process due to the short ramus or
- Ankylosing spondylitis
condylar deformity.
4. Neoplastic cause:-
3. Neoplastic cause: Due to any neoplasm of
- Primary or metastatic tumors of the condyle.
the coronoid process.
Appendix 8
(Healing of Wound)
HEALING OF WOUND 2. Callus formation- A rough woven bone or

primary callus looks overlap is formed in the next
Theme of Healing 10-20 days. A secondary callus, which form
Haverson systems during period of 3 weeks to
2 months.
3. Functional reconstruction - it takes 2 to 3 months.
Factors Influencing Wound Healing

1. Local factors:-
i. Infection delays healing.
ii. Poor blood supply delays healing.
iii. Foreign bodies delays healing.
iv. Movement delays healing.
v. Ionizing radiation delays healing.
vi. Ultraviolet light facilitates healing.
vii. Types, size and location of injury.
2. Systemic factors
i. Age Increasing age delays healing.
ii. Nutrition protein, vitamin C, zinc deficiency
delays healing.
iii. Systemic injection delays healing.
iv. Glucocorticoids has anti inflammatory
Healing of Bone (Three overlapping phases effect.
of bone healing, by Kruger) v. Uncontrolled diabetics delays healing.
1. Hemorrhage followed by organization of clot and vi. Hematological abnormalities delays healing.
proliferation of blood vessels- This is considered
as a non-specific phase occurs during 0-10 days.
Appendix 9
(Extraoral Injections)
TECHNIQUES FOR USE OF

EXTRAORAL INJECTIONS
A dental surgeon should familiarize himself with the
various techniques of the use of extraoral injections.
This is especially helpful to inject 1M, adrenaline
in case of anaphylaxis and IV drugs in case of other
emergencies like adrenal crisis. The various
techniques are:
1. Interdermal injection: Injection is introduced just
under the skin at an angle of 10-15 which will
raise a small weal. The area should be massaged
after removing the needle. The usual site of
injection is the lightly pigmented area of the
forearm where the reaction can be easily
observed.
2. Subcutaneous injections: The folds of the skin Site of IM injection
are raised between thumb and forefingers and
the needle is inserted at an angle of 45. After
insertion the plunger is withdrawn slightly to ensure
a blood vessel has not been entered. In case of introduced at 90. As in the subcutaneous
very short injection used for insulin, the needle technique the plunger is withdrawn to check for
enters the skin at 90. The area is not massaged inadvertent puncturing of a blood vessel. The
after withdrawing the needle but firm pressure fluid is injected slowly, the needle is withdrawn
is used to prevent hematoma formation. The quickly, pressure applied initially and then the
usual sites for subcutaneous injection are the outer area massaged gently.
aspect of the upper arm, the outer aspect of the 4. Intravenous injections: In case of intravenous
upper thigh and the skin of the abdominal wall. injection proper care must be taken to maintain
3. Intramuscular injections: This is given to muscles aseptic condition, proper injection drug and
so larger volume of solution can be injected volume should be checked. Any air bubbles must
(1-5 ml). The usual sites are the outer aspect be expelled from the barrel of the syringe before
of the thigh, locating the area in the middle third the needle is inserted into the tissues. The vein
of the space between the knee and greater chosen for injecting should be large and strong,
troachanter of the femur or the upper outer near the surface, not too freely movable, and
quadrant of the buttock. Alternatively the upper should be capable of being rendered turgid by
outer aspect of arm may be used if the muscle compression. If there are not fulfilled than the
is big enough. While giving an intramuscular operator may fail to locate the veins, tear its
injection, the skin is held but and the needle is wall or transfix it without realizing that the vein
Appendix9 275
has been entered. These mishaps cause distal to the place at which the vein is to be
unnecessary pain and brushing. The best site is punctured and advanced alongside the vein
within the bend of the elbow, where vein are before being introduced into the lumen. The
usually visible and often confirm to one of the plunger is withdrawn slightly to confirm entering
simple pattern as shown in Figure. The patients into the lumen of the blood vessel and than the
elbow is extended so that the vein is rendered solution is injected slowly. The pressure over the
turgid by compressing them proximally to the forearm is released, an antiseptic swab is held
chosen site by hand pressure, a tourniquet, a over the site of puncture and the needle is
piece of rubber tubing or sphygmomanometer withdrawn, pressure over the site of puncture
cuff inflated to 80 mm of mercury. The patient reduces the risk of hematoma formation, but
clenches his fist a few times and the operator should not be exerted until the moment that the
lightly taps the skin over the vein to distent it. needle is withdrawn, or it will cause pain. Pressure
The skin is punctured with the long axis of the must be maintained for a few minutes if bleeding
needle lying parallel to the vein with its bevel and brushing are to be prevented and the patient
uppermost. The point of the needle should be can often hold the swab firmly in position by
inserted through the skin at the site about 1 cm flexing his forearm.
SITE FOR IV INJECTION POSITION OF THE NEEDLE
Appendix 10
(Cryosurgery, Laser Surgery
and Electrosurgery)
CRYOSURGERY, LASER SURGERY AND 5. Collegen and autoimmune disease.

ELECTROSURGERY USED IN ORAL AND 6. Concurrent treatment with renal diseases or
MAXILLOFACIAL SURGERY immunosuppressive drugs.
7. Platelet deficiency disease
Cryosurgery 8. Blood dyscrasias of unknown origin.
9. Multiple myeloma.
Controlled destruction of tissues by freezing is known
10. Agammaglobulinemia.
as cryosurgery.
Complications
Types
1. Immediate:-
1. Liquid nitrogen
i. Pain during the freezing and thawing period.
2. Nitrous oxide
ii. Headache affecting forehead, temples, and
3. Carbon dioxide
scalp.
iii. Insufflations of subcutaneous tissue
Indication
iv. Interdermal hemorrhage.
1. Tumors with definable margins: v. Syncope
i. Nodular or ulcerated lesion. vi. Vesicular - bullous formation.
ii. Instrument delineation by means of a curette. vii. Edema
iii. Chemical delineation by means of 5-fluorouracil 2. Delayed:-
iv. Tumors overlying cartilage and bone i. Postoperative injections
v. Lentigo maligna ii. Febrile systemic reactions.
2. Nature of the neoplasm: iii. Hemorrhage from the wound site.
i. Infected tumors iv. Pyogenic granuloma
ii. Recurrent tumors from previous radiotherapy. v. Pseudo epitheliomeatous hyperplasia.
3. Patient with idiosyncrasies; 3. Prolonged:-
i. Patient with pacemaker. i. Hyperpigmentation
ii. Patient with anesthesia idiosyncrasies ii. Development of milia
iii. Patient old enough for surgical risks. iii. Hypertrophy scars
4. In operable patients:- iv. Neuropathy
i. Palliation 4. Permanent:-
ii. Removal of bulk vegetative lesions. i. Hyperpigmentation
ii. Ectopion and notching of eyelids
Contraindications iii. Notching and atrophy of tumor overlying
cartilage.
1. Intolerance to cold. iv. Tenting or notching of vermilion border of the
2. Cryogobulinemia. upper lip.
3. Raynaud's disease v. Atrophy
4. Cold urticaria vi. Alopecia of hair- bearing sites.
Appendix10 277
Laser Surgery Indications in Oral Surgery

'LASER' stands for 'Light Amplification by Stimulated 1. To reduce and treat mucositis caused due to
Emission of Radiation'. It is a device that emits an radiotherapy and chemotherapy.
intense, coherent directional beam of radiation 2. Pain reduction.
energy by stimulated electronic for molecular 3. To eliminate or reduce complications of
transitions to a lower energy levels. postoperative paresthesic.
4. For treating sinusitis.
Types 5. In combination with other treatment to treat TMJ
arthritis.
1. Carbon dioxide 6. To symptomatically treat tinnitus and vertigo
2. Neodymium YAG (Nd : YAG) patients.
3. Argon laser 7. Treat trigeminal neuralgia.
4. Tunable dye laser 8. Treat post herpetic neuralgia.
Advantages Electrosurgery
1. Production of a sterile surgical field, bactericidal, Electrosurgery is the use of electrodes for various
vircidal. surgeries instead of manual scalpel cutting.
2. Minimal cicatrix formation/ wound contraction.
3. Access too difficult to reach anatomic sites by
Armamentariums Needed
reflection or through wove guides.
4. Ability to coagulate, vaporizes, or incise tissues. 1. Dental electrodes.
5. Good hemostasis. 2. Coagulating electrodes.
6. Reduced local tissue trauma and edema. 3. Periodontal loop electrode curette.
7. Precise delivery of energy to diseased tissue via 4. Fine needle electrode.
microscopes for reduced damage to surrounding 5. Diamond electrode.
structure.
8. Reduced pain by induced neural anesthesia as Basic Requirements
a function of neuron sealing and decreased pain
mediator release. 1. Deftness with which the activated electrode is
9. Minimized tumor cell dispersion by lymphatic used.
sealing. 2. Choice of appropriate radio-frequency current.
3. Use of proper amount of current power output.
4. Soundness of the treatment plan.
Disadvantages
1. Specialized didactic and clinically oriented Uses in Dentistry
instruction required for laser use by the surgeon
and ancillary assistants. 1. Desensitizing hypersensitive dentine.
2. Hazards to patients, operating and assistant 2. Bleaching discolored teeth.
team, and an anesthesia personal from 3. Exposing sub gingival and other tissue-occluded
misdirected and inadvertent laser radiation. caries for definitive treatment.
3. Expense of laser equipment 4. Elongating clinical crown for improve esthetics.
4. Specialized wiring and plumbing connection. 5. Pulp capping.
5. Maintenance requirement. 6. Exposing the axial floors of proximal inlay
6. Fire hazard as related to anesthesia risk. preparations.
7. Electrical hazard of laser equipment. 7. Surgical exposure of partly erupted permanent
dentition.
Advantages 4. Absence of typical post operative sequalae such

as pain, swelling and trismus.
1. Electrosurgical cutting results from volatilization
5. Rapid uneventful healing by primary and
(vaporization) of the cells, hence bacteria, spores,
secondary intention with scar formation.
fungi or yeasts that contaminate the surgical field
6. Skin graft protection of the surgical site is not
are also volatilized and thus sterilization occurs
needed.
during cutting.
7. Healing is uniform throughout the depth of the
2. Tissue cleavage is totally atraumatic.
wound.
3. Electro surgery with RF current seals capillaries
producing hemostasis.
INDEX
A Higginsons chip syringe 57 Ryles nasogastric tube 61

hospital pattern elevator 50 scissors 56
Anesthesia in pediatric patients 87 Hovell lingual flap retractor 52 skin hook 57
Anesthesia in pregnancy 87 Howarth periosteal elevator 51 sponge holder 45
Antibiotics and antimicrobial agents Jenkins chisel 52 suction tips 60
acting against anaerobic organism 34 Jenkins Gouge 53 surgical blades 51
adverse reactions 34 Kays modified Austin retractor 51 Surgical burs 53
indications 34 Kelsey fry bone AWL 59 suture materials 61
mechanism of action 34 Kelsey fry mallet 53 suture needles 55
Armamentarium 45 Kilner skin retractor 52 towel chip 46
alar retractor 61 Langebeck retractor 52 tracheostomy tube 61
Allis tissue forceps 54 left upper molar dental extraction upper anterior dental extraction
apexo elevators 49 forceps 47 forceps 46
artery forceps 56 Lendo Levien elevator 49 upper pre-molar dental extraction
Aufright retractor 52 Lister sinus forceps 56 forceps 46
Babcocks tissue holding forceps lower anterior dental extraction upper pre-molar root extraction
59 forceps 48 forceps 47
bayonet forceps 47 lower molar dental extraction upper third molar forceps 47
bone rasp or file 54 forceps 49 volcanite burs 53
bone shears 54 lower pre-molar dental extraction
bone spreader 60 Volkmanns bone scoop 60
forceps 48
cartridge syringe 45 Walshans forceps 57
lower pre-molar root forceps 48
cheatel forceps 46 ward cheek retractor 52
malar bone elevators 58
cheek retractor 52 ward periosteal elevator 51
maxillary disimpaction forceps 58
chin retractor 59 Warwick James elevator 50
mayo needle holders 55
coleman elevator 49 winters cross bar elevator 50
Mclindoe nasal chisel 53
Collin reverdin needle 59 wire cutter 57
metal head frame 57
corrugated rubber dam 60 Armamentarium required for exodontia
Moons probe 50
couplands elevator or chisel 49 93
mosquito artery forceps 56
Cryers elevator 50 mouth mirror 45 elevators 94
dental mouth prop 50 needle holder 55 classification 94
dissection forceps 55 non-toothed dissecting forceps 55 indications 94
Doyen mouth gags 59 Obwegessors ramus retractor 59 precaution 94
endotracheal tube 60 periosteal elevator 51 principles 94
Erichs arch bar 60 read curette 54 extraction forceps 93
explorer 45 right upper molar dental extraction principles for the use of forceps
Ferussons mouth gag 59 forceps 47 93
Fickling forceps 54 root forceps 46 Aspects of the skull 261
Foleys self-retaining catheter 61 root separator (lower)-cow horn Autoclave 41
Gillies osteotome 53 49 parameter used 41
Hayton Williams wire twister 57 Rowe maxillary labial retractor 52 advantages 41
Hayton-Williams forceps 58 Rowes zygomatic arch AWL 59 disadvantages 41
B features 133 method of diagnosis 15

treatment 134 provisional diagnosis 13
-lactamase inhibitors 32 cavernous sinus thrombosis 133 Disinfection of selected dental
adverse reaction 33 features 133 instruments 43
classification 32 investigations 133 Distraction osteogenesis 228
indications 33 treatment 133 advantages 228
mechanism of action 33 mediastenitis 134 contraindications 228
Bicuspidization 169 meningitis 134 disadvantages 228
Birns hypothesis 104 features 134 indications 228
features 104 treatment 134 types of distractors 229
management 105 prognosis 133 Dryclave 42
mechanism 104 Conscious sedation 84 parameters used 42
Boiler 42 drugs 84 advantages 42
action of disinfectants and objectives 84 conventional method 42
antiseptics 42 Corticosteroids 35 disadvantages 42
parameter used 42 adverse reactions 36 short cycle 42
classification 35
C contraindications 36 E
dental indications 36
Caldwell-Luc operation 174 indications 35 Electrosurgery 277
Cardiopulmonary resuscitation 30 Cryosurgery 276 advantages 278
objectives 31 complications 276 armamentariums needed 277
patient evaluation 31 contraindications 276 basic requirements 277
Case history format used in oral and indication 276 Endodontic microsurgery 170
maxillofacial surgery 265 types 276 classification 166
clinical examination 265 Luebke-Ochesenbein flap 166
dental examination 265 semi lunar flap 166
general examination 265 D
contraindications 165
personal details 265 Development of mandible 264 Endodontic surgery 165
Characteristic of an ideal ridge for best Diagnosis in oral and maxillofacial indications 165
denture support 148 surgery 5 Etiology of dentofacial fracture 236
ridge correction procedures 148 components of patients history 6 Exodontia 91
hard tissue procedures 148 chief complaint of the patient contraindications 91
soft tissue correction 152 7 absolute contraindication 92
ridge extension procedure 154 family history 9 relative contraindications 91
mandibular procedures 155 general examination 9 indications 91
maxillary procedures 154 local examination 12 pre-operative assessments 92
ridge reconstruction or past medical history 9 Extraoral injections 274
augmentation procedures 158 routine information 6
Chemiclave 42 social and occupational history
parameters used 42
F
9
Cleft lip and cleft palate 224 differential diagnosis 13 Facial clefts 225
Complications of exodontia 100 importance of case history 5 cheilorrhaphy 226
operative complications 100 investigations 13 classification 225
postoperative complications 103 biochemical investigations 14 difficulties and problems 225
Complications of fracture treatment hematological investigations etiology 225
257 13 management 226
after treatment 257 histological investigation 15 palatorrhaphy 227
during treatment 257 microbiological investigations Facial nerve neurology 69
Complications of odontogenic infection 17 branches of the facial nerve 70
133 radiological investigation 14 course of the facial nerve 69
brain abscess 133 urine analysis 14 Facial swelling 270
Index 281
Features of maxillofacial deformities contraindications 107 theories of local anesthesia action
218 frequency 106 72
Foramina of the skull 264 indications 107 acetylcholine theory 72
Fractures of the jaw 235 pre-operative assessment 107 calcium displacement theory
applied anatomy 235 Impulse conduction in a nerve fibre 67 73
lower facial skeleton 235 Inability to open mouth 272 membrane expansion theory
mid-facial skeleton 235 Infection control 40 73
upper facial skeleton 235 Infection of the pulpal and periapical specific receptor hypothesis 73
general diagnosis 238 tissues 125 surface charge theory 73
general treatment 239 etiology 125 Ludwigs angina 132
principles of fracture management Intentional replantation 169 etiology 132
240 contraindications 169 features 132
Functional endoscopic sinus surgery procedure 169 microbiology 132
(FESS) 177 pathogenesis 132
K prognosis 133
G
Kelsey fry 113 M
General anesthesia 84
classification 85
L Mandibular fractures 254
complication 86
angle fracture 256
pareanesthetic evaluation of patient
Laser surgery 277 features 256
85
advantages 277 body fracture 256
stages 85
disadvantages 277 features 256
General features in Lefort fractures 252
indications 277 condylar fracture 254
types 277 classification 254
H Lefort-1 fracture 250 features 255
Healing of wound 273 features 251 coronoid fracture 256
Hemisectioning 170 Lefort-II fracture 251 features 256
Hemorrhage 28 features 251 parasymphisis and symphisis
causes 28 Lefort-III fracture 252 fracture 256
management of intraoperative features 252 features 256
hemorrhage 28 Lignocaine hydrochloride as local ramus fracture 256
postoperative hemorrhage 28 anesthetic agent 77 features 256
primary hemorrhage 28 Local anesthesia 72 Mastigatory spaces 130
control of primary hemorrhage classification of local anesthetic Maxillary sinus 171
29 agent 73 anatomy 171
control of secondary according to biological site and classification of the disorders 172
hemorrhage 29 mode of action 74 diagnosis of the disorders 172
reactionary hemorrhage 28 according to chemical structure functions 172
Hemostatics 37 73 Medical emergencies 18
Hiltons method of abscess drainage according to solubility 74 cardiac conditions 18
125 complication 76 angina pectoris 19
Hyperbaric oxygen therapy 145 anesthetic solution 76 congestive cardiac failure 19
advantages 146 needle insertion problem 77 hypertension 19
contraindications 145 composition of local anesthetic myocardial infarction 19
indications 145 solution 73 hormonal conditions 20
mechanisms 145
contraindications 75 acute adrenal insufficiency 21
effect 75 acute hypoglycemia 20
I indications 75 diabetes 21
Impaction 106 mechanism of action 74 hyperthyroidism 21
causes 106 pharmacokinetic 74 other conditions 22
complication 106 requisition 74 anticoagulant therapy 23
hepatic insufficiency 23 treatment 191 147

renal insufficiency 22 Orbital floor fracture 253 ridge reconstruction or
seizure disorder 23 diagnosis 254 augmentation procedures 147
respiratory conditions 19 fractures 254 Primary mandibular spaces 128
acute asthmatic episode 20 treatment 254 Primary maxillary spaces 127
chronic obstructive pulmonary Oro-antral fistula 175 Principles of exodontia 95
disease (COPD) 20 clinical features 175 Principles of flap design 98
management of patient with diagnosis 175 Principles of surgery 3
asthma 19 etiology 175 cleaning the field of operation 3
Millards rotation flap 226 treatment 176 cutting bone 3
Millers elevator 116 Orofacial cysts 179 principles of adequate access 3
classification 179 principles of arrest of hemorrhage
N complication of treatment 183 3
diagnosis 180 principles of asepsis 3
Nasal antrostomy 174 pathogenesis 180 principles of control and prevention
Nasoethmoidal fractures 250 treatment 181 of infection of wound 4
features 250 enucleation 182 principles of debridement (toilet of
treatment 250 marsupialization 181 wound) 3
Nerve physiology 67 Orofacial tumors 186 principles of drainage 4
axon 67 diagnosis 186 principles of minimal damage 3
dendrite 67 treatment 187 principles of painless surgery 3
nerve cell body 67 Orthodontic surgery 215 principles of repair of wounds 4
Neurogenic disorders 230 Osteomyelitis of jaw 137 principles of support to the patient
classification 230 classification 137 4
Non-insulin dependant diabetes 22 clinical features 138 retraction 3
Non-odontogenic tumors 186 etiology 137 Principles of suturing 63
classification 186 investigations 139
pathogenesis 138 R
O treatment 139
Osteoradionecrosis 143 Removal of the buccal bony plate 98
Odontogenic infection 122 clinical features 143 Removal of the impacted teeth 113
clinical features 122 management 144
diagnosis 122 pathogenesis 143 S
differential diagnosis 123
procedures 123 Salivary gland disorders 193
P
treatment 123 classification 197
principles for the use of Pain control 34 complications 200
prophylactic antibiotics Pathway of dental infection 122 diagnosis 194
124 Pericoronitis 134 secretion 194
principles for the use of features 134 surgical treatment 195
therapeutic antibiotics treatment 135 Shock 25
124 types 134 features 26
principles of incision and Peritonsillar abscess 135 management 26
drainage 125 features 136 pathogenesis and classification 26
Odontogenic tumors 186 treatment 136 Skeletal muscle relaxants 36
classification 186 Potts elevator 116 adverse reactions 37
Oral malignancies 189 Preprosthetic surgery 147 classification 36
classification 190 aims 147 indications 37
diagnosis 191 classification 147 Spaces involved in odontogenic
etiology 190 ridge correction procedures infections 127
general features 190 147 primary spaces 127
grading and staging 191 ridge extension procedures secondary spaces 127
Index 283
Specific features in treatment of diagnosis 200 Syncope 25
mandibular fracture 256 types 200 management 25
Specific fractures of dentofacial region Study of some common temporomandi- prodrome 25
247 bular joint disorders 208 syncopal episode 25
dento-alveolar fractures 247 extracapsular disorders 213 types 25
zygomatic complex fractures 247 myofunctional pain dysfunction
classification 247 syndrome 213 T
clinical features 247 intracapsular disorders 208
treatment 248 ankylosis 210 Tachyphylaxis 26
Sterilization 40 degenerative joint disease 208 Technique for extraction of tooth 95
classification of the agents 40 developmental joint disorders Technique used for anesthesia in
chemical agents 41 209 dentistry 78
physical agents 40 infective joint diseases 209 Techniques of implant surgery 161
methods of sterilization 43 inflammatory joint diseases endosteal implant insertion 161
principles of sterilization 42 209 subperiosteal implant insertion 163
Study of commonly impacted teeth 110 Study of some neurogenic disorders 230 transosteal impression insertion
classification 110 Bells palsy 233 163
impacted mandibular 3rd clinical features 233 complications 163
molar 110 etiology 233 features 163
impacted maxillary 3rd molar treatment 233 management 163
112 glossopharyngeal neuralgia 234 Temporomandibular joint disorders
impacted maxillary canine 113 201
features 234
Study of individual endodontic surgical applied anatomy and physiology
traumatic injuries 230
procedures 167 201
axonotemesis 230
apicoectomy with or without articular disc 201
neurapraxia 230
retrograde filling 167 articulating surface 201
neurotmesis 231
procedure 167
trigeminal neuralgia 231 ligaments 201
Study of maxillary sinus disorders 172
clinical features 231 classification 203
chronic maxillary sinusitis 173
diagnosis 232 extracapsular 203
clinical features 173
etiology 231 intracapsular 203
complication 174
treatment 232 diagnosis 203
etiopathogenesis 173
Study of some pulpal and periapical nerve and blood supply 201
management 174
maxillary sinusitis 172 infections 125 development 202
clinically features 173 acute pulpitis 126 functional movements 202
management 173 features 126 nerve supply 201
types 172 apical periodontal cyst 126 vascular supply 202
Study of orthodontic surgical features 126 surgical approaches 204
procedures 215 chronic apical periodontitis 126 surgical treatments 206
Study of salivary gland disorders 197 features 126 Tetracycline 34
bacterial sialadenitis 197 periapical and periodontal abscess adverse reactions 34
clinical features 197 126 indications 34
treatment 197 features 126 mechanism of action 34
mucocele and ranula 198 pulp polyp 125 Therapeutics in oral surgery 31
neoplastic lesions 199 features 126 Transalveolar technique of extraction
sialolithiasis 198 pulpal hyperemia 125 97
clinical features 198 features 125 advantages 98
diagnosis 198 Sulfonamides 33 indications 97
etiopathogenesis 198 adverse reactions 33 steps 98
treatment 198 classification 33 Treatment of edentulous patients 246
Sjgrens syndrome 200 indications 33 Trephination 170
clinical features 200 mechanism of action 33 Trigeminal nerve neurology 70
branches of the trigeminal nerve chronic focal sclerosing V

70 osteomyelitis 142
Various nerve blocks used in dental
mandibular division 71 features 142 practice 79
maxillary division 71 Garres osteomyelitis 142
ophthalmic division 70 features 142 W
mesencephalic root 70 infantile osteomyelitis 142
motor root 70 White lesions 271
features 142 diagnosis 271
sensory root 70
differential diagnosis 271
Types of flaps and incision 114 U
Types of osteomyelitis 142 Z
actinomycotic osteomyelitis 143 Usage of various local anesthesia
features 143 techniques in dentistry 83 Ziehl-Neelsen staining 17

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JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

A Concise Textbook of Oral and Maxillofacial Surgery

2009, Sumit Sanghai, Parama Chatterjee

First Edition: 2009

Typeset at JPBMP typesetting unit

Arun Jacob Silas

Sumit Sanghai Parama Chatterjee

UNIT II: ANESTHESIA

UNIT III: EXODONTIA

UNIT IV: MINOR ORAL SURGERY

18. Surgical Procedures in OrthodonticsOrthodontic Surgery 215

DEFINITION is done to gain adequate access to the

7. Principles of drainage: Wound are drained complete debridement is done. Wound

DEFINITION ethnic group, occupation, marital status,

f. Expression of interest, warmth and Ewings sarcoma

Torus mandibularis For example:

iv. Loose teeth Decreased salivary flow

b. Reasons for loss of teeth towards v. Medication: A medication history is essential

iv. Endocranial cause Types of Fever

JNC classification of blood pressure: Palpating lymph nodes and probable

vi. Floor of mouth: Observe for the opening INVESTIGATIONS

xi. Blood urea = 10-20 mg percent v. Serum billirubin

Structure to be Radiographic technique 3. Screening of normal tissues from abnormal

It is quick, simple, painless and bloodless 6. Microbiological Investigations

Management of Patient 3. Use an anxiety reduction protocol.

4. Consult physician about possible use of Management of a Patient with

Severe Hypoglycemia Management of Patient Suffering

7. If allowed, have the patient eat a normal During Appointment

Syncope 2. Loosen tight clothing.

Pathogenesis and Classification iii. Irreversible stage

Local Anesthesia Toxicity Contd....

Manifestations and Management of LA toxicity Manifestation Management

Manifestation Management objects; suction oral cavity

Management of Respiratory Tract Foreign Body

Hemorrhage Packing with oxidized cellulose or any

Control of Primary Hemorrhage

Control of Secondary Hemorrhage

Management of Patient Who is Pregnant

Its main function is to re-establish cardiac and

Mechanism of Action SULFONAMIDES

TETRACYCLINE (BROAD Trichomoniasis

2. Indoles Metabolic acidosis

Gout Adverse Reactions

b. short acting used for packing wound and bleeding

Emergency Drugs for the Dental Office

General Drug Group Common Examples

Drug Interactions Common in Dental Practice

No. Drug Interacting Drug Effect Seen

FURTHER READING 5. Malamed SS Handbook of medical emergen-

DEFINITIONS on tissues which are in contact with micro-

6. Heat AUTOCLAVE (STEAM UNDER

CHEMICLAVE (CHEMICAL UNDER Inaccurate calibration, lack of setting and

Methods of Sterilization or Disinfection of Selected Dental Instruments

Items Steam autoclave Dry heat oven Chemical sterlization

(A) (B) (C)

Fig. 4.4: Patient preparation

FURTHER READING 4. Daniel M Laskin Oral and maxillofacial surgery.

Fig. 5.1: Explorer (dental probe)

Mouth Mirror (Fig. 5.2) Fig. 5.4: Sponge holder

It has two partsthe mirror top and the

Fig. 5.5A: Cartridge syringe

Sponge Holder (Fig. 5.4)