We Care For Your Smile

Preformed anatomic metal crown

2012-02-27T04:34:00.001-08:00

Preformed anatomic metal crown procedure has been explained in the following steps:

The procedure consists of

1.Minimal tooth preparation.

2.Measurement and selection of crown.

3.Trimming and adaptation of gingival margin.

4.Occlusal adjustment.

5.Cementation.

Armamentarium needed for the preparation:

1.High speed hand piece

2.No.170 bur

3.Measuring gauge

4.Crown forms

5.Stretching block.

6.Crown and bridge scissors

7.Contouring pliers

8.Straight handpiece

9.Sandpaper disc on moore mandrel

10.Articulating paper

11.Miller forceps

12.Cement spatula

13.Paper pad

14.Zinc-oxide eugenol cement

15.Petrolatum

16.Curved burnisher

17.Explorer

18.Mouth mirror

19.Dental floss

Preparation of the tooth:

Occlusal clearance is obtained with a no.170 bur.

A functional cusp bevel is placed with the same bur.

Proximal reduction which is done next,usually consists of removing an existing amalgam restoration.

A measuring gauge for selecting a preformed metal crown.

Obtain the mesiodistal measurement of the tooth.

The gingival margins can be flared slightly on the stretching block.

Estimate the marginal ridge height discrepancy between the restoration and the adjacent tooth.

Remove the estimated excess height from the gingival margin.

Smooth the gingival margin.

Contour the axial surfaces with pliers.

Check the occlusion with articulating paper.

Seat the crown filled with zinc oxide-eugenol cement.

Burnish the margin.

Remove excess cement from the interproximal region with dental floss.

All the excess cement must be removed from the crevice with an explorer.

Construction of the custom tray for making complete denture

2012-02-25T21:37:00.000-08:00

Construction of the custom tray is done by the following procedure..Baseplate wax approximately 1 mm thick is placed on the cast within the outlined border to provide space in the tray for the final impression material.The posterior palatal seal area on the cast is not covered with the wax spacer.Therefore the completed custom tray will contact the mucous membrane across the posterior palatal border and additional stress placed here during the making of the final impression will help achieve a posterior border seal..In addition this part of the tray will act as a guiding,stop to help position of the tray will act as a guiding stop to help position the tray properly during the impression procedure..A wax spacer will not be used if a tray properly during the impression procedure..A wax spacer will not be used if a metallic oxide impression paste has been selected for making the final impression..

The custom tray should be 2 to 3 mm thick with a stepped handle in the anterior region of the tray to facilitate removal from the mouth.The step should be sufficient height to avoid distortion of the upper lip when the tray is in the mouth..

Preliminary impressions for making complete denture

2012-02-25T21:31:00.000-08:00

Preliminary impressions for making complete denture are done by making use of stock trays..Stock trays are constructed in either metal or plastic and may be perforated or unperforated..They cannot fit the uppper jaw of each individual without distorting the soft tissues.It is important that the preliminary impression is as accurate as possible..An unsatisfactory preliminary impression will result in an unsatisfactory custom tray..Correctly selected stock tray will not fit the denture bearing area perfectly..When making the impression,it is advisable to select an impression material that has a relatively high viscosity therby allowing the material to compensate more easily for the deficiencies of the tray..The most suitable impression materials are alginate(irreversible hydrocolloid) or impression compound.

Impression compound is a thermoplastic material with a high viscosity.The material will flow beyond the tray to compensate for under extension and will support itself in this position once it is chilled..It is not necessary to correct any under extension of the stock tray before using this material..Also additions can be made to it if part of the impression is deficient.It’s high viscosity means that it records surface detail poorly..It is non-elastic and so will not record undercuts accurately..Impression compound has many advantages as a preliminary impression material..

A better understanding of the macroscopic and microscopic anatomy plus physiology of the dentulous area can be obtained by using the highly viscous aliginate impression material..The irreversible hydrocolloids record detail accurately if they are properly controlled.They do not absorb the mucous secretions from the palate and they can also exhibit defects in the palatal part of the impression..Irreversible hydrocolloids lose moisture rapidly and can change their size..The casts must be poured soon after the impressions are made or removed from the mouth.The weight of the dental stone of the cast may be sufficient to distort the borders of the impression if they are not supported by the boredrs of the tray..

Impression trays for making complete denture

2012-02-25T05:14:00.000-08:00

Impression trays while making complete dentures are the most important part of the impression making procedure..If it is too large,it will distort the tissues around the borders of the impression and will pull the soft tissues under the impression and will pull the soft tissues under the impression away from the bone,distorting the dimensions of the sulcus in the process..If it it too small,the border tissue will collapse inward on to the residual ridge.This too will distort the accurate recording of the border extension of the denture and prevent the proper support of the lips by the denture flange.A properly formed tray enables the dentist to carry the impression material to the mouth and control it without distorting the soft tissues that surround it...

Individual or custom trays have borders that can be adjusted so they control the movable soft tissues around the impression but do not distort them.Space is provided inside the tray so that the shape of the tissues covering the denture bearing area may be recorded with minimal or selective displacement.Because each mouth is different,these requirements cannot be achieved successfully with stock trays.Impression procedures involve making a preliminary impression only in a stock tray..This is then poured up in dental stone and the resulting cast is used to constructed a custom tray..The final impression is then made using a custom tray...

Impression making for complete denture

2012-02-25T05:06:00.001-08:00

Before making the preliminary impression for complete denture,it is advisable to practice placing the tray in position..The patient is asked to open the mouth halfway and the tray is first centred below the upper residual ridge.The upper lip is elevated and the tray is carried using the frenum as a centering guide..When the tray is located properly anteriorly,the index fingers are placed in the first molar region on each side of the tray and with alternating pressure.

If the impression compound is used for making the preliminary impression the technique is the same except that the borders of the stock tray are not modified with wax..There is no need to use a tray adhesive and preloading of the palate and around the tuberosities is not undertaken.The tray is loaded with the softened impression composition and seated in the mouth in exactly the same manner as for alginate impression material

Focal reversible pulpitis

2012-02-16T22:33:00.000-08:00

Focal reversible pulpitis is also known as pulp hyperemia..Vascular dilatation occurs from the pumping action during tooth extraction and as a result there is dentinal and pulpal irritation..This early mild transient pulpitis is seen at the pulpal ends of irritated dentinal tubules and is known as focal reversible pulpitis..

Clinical features:

A tooth with focal reversible pulpitis is sensitive to thermal changes.Application of ice or cold fluids to the tooth results in pain but it disappears on removal of the thermal irritant..The tooth also responds to a stimuli by an electric pulp tester at a lower level of current indicating a lower pain threshold.Focal reversible pulpitis is seen in deep carious lesions,large metallic restorations without inadequate insulation and restorations with defective margins..

Histologic features:

There is dilatation of pulp vessels..The edema fluid may collect because of damage to the capillary walls allowing extravasation of white blood cells or diapedesis of white blood cells.Self strangulation of the pulp may occur as a result of increased arterial pressure occluding the vein at the apical foramen..

Treatment and Prognosis:

Focal reversible pulpitis as the name suggests is reversible and so a carious lesion should be excised and restored..A defective filling if present must be removed and refilled properly..

Dentigerous cyst - Eruption cyst - Follicular cyst

2012-02-12T21:53:00.000-08:00

Dentigerous cyst is also known as eruption cyst or follicular cyst..It originates after the crown of the tooth has been completely formed by accumulation of fluid between the reduced enamel epithelium and the tooth crown..Dentigerous cyst usually involves the crown of a normal permanent tooth..

Clinical features:

Dentigerous cyst is associated with the crown of an impacted,embedded or unerupted tooth.It can also be supernumerary tooth.The most common sites of this cyst are the mandibular and maxillary third molar and maxillary cuspid areas..Expansion of bone with facial asymmetery,extreme displacement of teeth,severe root resorption and pain are seen associated with this cyst..This cyst also grows in size over time..It the cyst involves an unerupted third molar there is a hollowing out of the entire ramus extending up to the coronid process and condyle and also expansion of the cortical plate due to the pressure exerted by the lesion..The lesion appears as a circumscribed,fluctuant and translucent swelling of the alveolar ridge over the site of the erupting cyst..When the circumcoronal cystic cavity contains blood,the swelling appears purple or blue and it is termed eruption hematoma.

Roentgenographic features:

A radiolucent area is seen associated with an unerupted tooth crown.If there has been a displacement of the tooth the radiolucent area may appear to project laterally from the tooth crown..In case of a circumferential dentigerous cyst the cyst surrounds the entire crown of the tooth without involving the occlusal surface so that the tooth may erupt through the cyst as through the hole of a doughnut..The dentigerous cyst is a smooth unilocular lesion but may be multilocular at times..The radiolucent area is surrounded by a thin sclerotic line representing bony reaction..

Histologic features:

Dentigerous cyst is composed of a thin connective tissue wall with a thin layer of stratified squamous epithelium lining the lumen.Rete peg formation is absent.The connective tissue wall is quite thickened composed of a very loose fibrous connective tissue or sparely collagenized myxomatous tissue..Inflammatory cell infiltration of the connective tissue is common.Cysts which exhibit inflammation contain Rushton bodies within the lining epithelium..These are peculiar linear,often curved,hyaline bodies..

Treatment:

The treatment of the dentigerous cyts depends entirely on the size of the lesion..Smaller lesion can be removed surgically..In case of larger cysts which involve serious loss of bone are treated by insertion of a surgical drain or marsupialization.This results in relief of pressure and the gradual shrinking of the cystic space by peripheral apposition of new bone.

Complications:

1.Development of ameloblastoma either from the lining epithelium or from rests of odontogenic epithelium in the wall of the cyst.

2.The development of epidermoid carcinoma from the same two sources of the epithelium.

3.The development of a mucoepidermoid carcinoma.

Chicken pox - Varicella zoster

2012-02-11T22:12:00.000-08:00

Chicken pox or varicella zoster is an acute viral disease that usually occurs in children..The incubation period is about two weeks..It closely resembles small pox..The mode of transmission is by airbornes droplets or direct contact with infected lesions.The portal of entry is through the respiratory tract...

Clinical features:

The disease is characterised by head ache,nasopharyngitis and anorexia followed bymaculopapular or vesicular eruptions of the skin and low grade fever..These eruptions usually being on the trunk and spread to involve the face and extremities..The lesions of the skin eventually rupture and form a superficial crust and heal by desquamation..The disease lasts for about a week to 10 days..There may be a secondary infection of the pustules in some leaving behind small pitting scars upon healing...

Oral manifestations:

Small blister like lesions involve the oral mucosa,tongue,gingiva and palate as well as the mucosa of the pharynx..The mucosal lesions are slightly raised vesicles with a surrounding erythema and rupture soon after formation and form small eroded ulcers with a red margin closely resembling aphthous lesions...

Complications:

Encephalitis and pneumonia occur occasionally..Children with chronic diseases and those receiving cortisone therapy or those with malignancies and receiving chemotherapy are prone to develop a severe or fatal form of the disease…

Dealing with chicken pox

Mumps - Epidemic parotitis

2012-02-11T21:58:00.000-08:00

Mumps or epidemic parotitis is an cute contagious viral infection characterised by unilateral or bilateral swelling of the salivary glands usually the parotid gland..It is a disease of the childhood but it can affect adults also..Mumps has an incubation period of two to three weeks..

Clinical feattures:

The disease is usually preceded by an onset of headache,chills,moderate fever,vomiting and pain below the ear..These symptoms are followed by a firm and somewhat rubbery or elastic swelling of the salivary glands elevating the ear and this usually lasts for about 1 week..This salivary gland involvement produces pain upon mastication or chewing..The virus is present in the saliva of the affected persons..Droplet dissemination and infection are common..The papilla of the opening of the parotid duct on the buccal mucosa is often puffy and reddened..

Complications:

Organs affected include testes,ovaries,pancreas,mammary glands,prostrate,epididymis and heart..When mumps involves the adult male,orchitis is a great danger as complete sterility results..Involvement of the pancreas produces an acute pancreatitis which causes an elevation in serum lipase..Serum amylase is also elevated..Meningoencephalitis,deafness and mastitis are also occasional complications…

Odontogenic keratocyst

2012-02-08T21:32:00.000-08:00

Odontogenic keratocysts are characterised by a parakeratisnised surface which is typically corrugated.There is a remarkable uniformity of thickness of the epithelium usually ranging from 6 to 10 cells in thickness.There is also a prominent palisaded polarised basal layer of cells often described as having picket fence or tomb tone in appearance..

The Odontogenic keratocyst originates from dental lamina which still possess marked growth potential or from proliferation of basal cells as a residue or remnant of oral epithelium.The epithelium of the Odontogenic keratocyst has been shown to be far more active than that in most other odontogenic cysts as judged by greater mitotic activity.

Clinical features:

The cyst may occur at any age from the very young to the the very elderly.The peak incidence is in the second and third decades of life with a gradual decline therafter.There is predilection for occurrence in males.The mandible is invariably affected more frequently than the maxilla.In the mandible the cysts occur in the ramus-third molar area followed by the first and second molar area and then the anterior mandible.In the maxilla the most common site is the third molar area followed by the cuspid region.

The common features of Odontogenic keratocyst are pain,soft-tissue swelling and expansion of bone,drainage and various neurologic manifestations such as paresthesia of the lip or teeth.

Roentgenographic features:

The lesion may appear as either a unilocular or multilocular radiolucency with a thin sclerotic border representing reactive bone.This border may be smooth or scalloped but it is generally sharply demarcated.The Odontogenic keratocysts are associated with impacted or unerupted teeth.Proximity to the roots of adjacent normal teeth sometimes causes resorption of these roots although displacement is more common.These cysts displace the neurovascular bundle.

Histologic features:

The Odontogenic keratocyst wall is usually thin unless there has been a superimposed inflammation.The lining epithelium is highly characteristic as it is composed of parakeratin surface which is usually corrugated,rippled or wrinkled.A uniformity of thickness of the epithelium between 6 and 10 cells in depth wihtout rete peg formation and a polarised and palisaded basal layer of cells.The connective tissue wall shows small islands of epithelium similar to the lining epithelium.The lumen of the Odontogenic keratocyst may be filled with a thin straw coloured fluid or with a thicker creamy material.Cholesterol and hyaline bodies also may be present at the sites of the inflammation.The Odontogenic keratocysts are highly recurrent.

Treatment and Prognosis:

The Odontogenic keratocyst must be surgically excised.Complete redication of the cyst may be difficult as the cyst wall is very thin and may easily fragment.The perforation of the cortical bone in lesions involving the ramus is common and complicates total removal of the cyst.There are three methods of removing the Odontogenic keratocyst.They are

1.Marsupialization.

2.Enucleation and primary closure.

3.Enucleation and packing open.

Enameloma

2012-02-08T21:28:00.000-08:00

Enameloma is an ectodermal tumour of odontogenic origin. Enameloma is not a true neoplsam and may be classified as a tumour only by virtue of the fact that it constitutes a small,focal excessive mass of enamel on the surface of a tooth.The enamel pearl is mostly frequently found near or in the bifurcation or trifurcation of the roots of teeth or on the root surface near the cemento-enamel junction.It appears as a tiny globule of enamel firmly adherent to the tooth which arises from a small group of misplaced ameloblasts.This enamel sometimes contains a small core of dentin and a small strand of pulp tissue extending from the pulp chamber or root canal of the tooth.The Enameloma is of no clinical significance but clinically and roentgenographically it may be mistaken for calculus.

Classification of odontogenic cysts

2012-02-08T21:24:00.000-08:00

Odontogenic cysts are classified as follows

1.Primordial cyst

2.Dentigerous cyst

a.Eruption cyst

3.Periodontal cyst

a.Apical periodontal cyst

b.Lateral periodontal cyst

4.Gingival cyst

a.Newborn(dental lamina cyst)

b.Adult

5.Odontogenic keratocyst

a.Basal cell nevus-bifid rib syndrome

6.Calcifying odontogenic cyst

Diphtheria

2012-01-14T00:58:00.000-08:00

Diphtheria is an acute contagious disease caused by a gram positive bacillus,Corynebacterium diphtheriae.This infection occurs frquently in children during the fall and winter months.The microorganism inhabits the upper respiratory tract of man and is transmitted through droplet infection or by direct contact.

Clinical features:

The incubation period for diphtheria only only a few days.The disease is manifested by listlessness,malaise,headache,fever and occasional vomiting.The patient will complain of sore throat.Mild redness and edema of the pharynx is seen.Cervical lymphadenopathy is often seen.

Oral manifestations:

There is formation of a patchy “diphtheritic membrane” which often begins on the tonsils and enlarges becoming confluent over the surface.This false membrane is a grayish,thick,fibrinous,gelatinous-appearing exudate which contains dead cells,leukocytes and bacteria overlying necrotic,ulcerated areas of the mucosa and covering the tonsils,pharynx and larynx.It tends to be adherent and leaves a bleeding surface if stripped away.This diphtheritic membrane is also seen on the uvula,soft palate and gingiva.The soft palate may become temporarily paralysed during the third to fifth weeks of the disease.These patients will have a peculiar twang and may also exhibit nasal regurgitation of liquids during drinking.This paralysis usually disappears after few weeks or months.If the infection spreads unchecked in the respiratory tract,the larynx may become edematous and covered by the pseudomembrane.This causes a mechanical obstruction and the typical cough or diphtheritic croup occurs.If the airway is not cleared suffocation may result from this obstruction.

Complications:

During or after this disease compliccations are usually seen in the cardiovascular and nervous systems as a result of toxaemia.Both myocarditis and polyneuritis may develop.Acute interstitial nephritis may also occur in the kidneys.There is a complete recovery,however,the disease must be taken seriously and proper treatment taken accordingly.

Prevention:

The disease is prevented by prophylactic active immunization with diptheria toxoid(DTP vaccine).

Treatment:

The disease is treated with antitoxin along with antibiotics as soon as the diagnosis is made.

Immunisation schedule for kids

Leprosy

2012-01-14T00:42:00.000-08:00

Leprosy is a chronic granulomatous infection caused by an acid-fast bacillus,Mycobacterium leprae.

Leprosy has ben classified in to two categories:

1.Tuberculoid leprosy(TT)

2.Lepromatous leprosy(LL)

a.Bordeline tuberculoid(BT)

b.Borderline leprosy(BB)

c.Borderline lepromatous(BL)

Clinical features:

The tuberculoid lesions are characterised by single or multiple macula,erythematous eruptions with dermal nerve and peripheral nerve trunk involvement resulting in loss of sensation.The lepromatous lesions develop early erythematous macules or papules that sunsequently lead to progressive thickening of the skin and characteristic nodules.These develop on any skin area and cause severe disfigurement.Facial paralysis may also occur due to nereve involvement.The disease runs a chronic course and seldom causes sudden death.

Oral manifestations:

The oral lesions seen are small tumour like masses called as lepromas which develop on the tongue,lips or hard palate.These nodules show a tendency to break down and ulcerate.Gingival hyperplasia with loosening of the teeth has been seen.

Histologic features:

The typical granulomatous nodule shows collections of epithelioid cells and lymphocytes in a fibrous stroma.Langhans type giant cells are present.Vacuolated macrophages called lepra cells are scattered throughout the lesions and contain the bacilli.

Treatment:

Long term chemotherapy is initiated upon diagnosis.

Adenoid cystic carcinoma - Cylindroma

2012-01-13T01:07:00.001-08:00

Adenoid cystic carcinoma is otherwise known as cylindroma..It is a malignant tumour..The palatal mucos ais the most frequent site of occurrence.

Clinical features:

The salivary glands involved are the parotid,submaxillary and the accessory glands in the palate and tongue.The tumour occurs commonly during the fifth and sixth decades of life.The clinical manifestations seen are early local pain,facial nerve paralysis in the case of parotid tumours,fixation to deeper structures and local invasion.The intraoral tumours exhibit surface ulceration.

Histologic features:

The adenoid cystic carcinoma is composed of small deeply staining uniform cells resembling basal cells that are commonly arranged in anastomosing cords or a duct like pattern,the central portion of which may contain mucoid material producing the typical cribriform,honey- comb or swiss cheese patter.The stromal connective tissue becomes hyalinized and surrounds the tumour cells forming a structural pattern of cylinders from which the lesion originally derived the name’Cylindroma’.Spread of the tumour cells along the perineural spaces or perineural sheaths is a common feature of this neoplasm.

Treatment and Prognosis:

The treatment of Adenoid cystic carcinoma is surgical excision.X-ray radiation is also given after the surgical treatment.Cervical node involvement also occurs in this tumour.Distant metastases to lung,bones and brain occurs.The cure rate for patients with this disease varies from person to person but is discouragingly low.

Kaposi’s sarcoma

2012-01-13T01:05:00.001-08:00

Kaposi’s sarcoma is malignant tumour of connective tissue..Kaposi’s sarcoma is an unusual and uncommon disease of blood vessels which occasionally manifests in the oral cavity.Kaposi’s sarcoma is an infectious granuloma or a retituloendothelial hyperplasia.

Clinical features:

Kaposi’s sarcoma may occur at any age but it is common in the fifth,sixth and seventh decades.The multiple skin lesions originate on the extremities but also involve the face and oral cavity and many visceral organs and lymphnodes.They may appear reddish or brownish-red nodules which may vary in size from a few millimeters to a centimeter or more in diameter and are less painful and tender.The lesions of the mucosa are identical in appearance with the cutaneous nodules.Cervical lymphnodes and salivary gland involvement is also seen..

Histologic features:

The lesion may consist of numerous small capillary type blood vessels which may or may not be blood containing.The lesions are extremely cellular consisting of proliferating masses of embryonic appearing spindle cells of varying size,shape and appearance showing occasional mitoses with hyperemic vascular slits.Inflammatory cell infiltration is seen.The development of the disease takes place in three stages:inflammation,granuloma and neoplasia.

Treatment and Prognosis:

Surgical eradication of the disease is dffcult because of the multiplicity of the lesions.X-ray radiation has been used for treatment.Chemotherapeutic agents have also been used beneficially

Fibroma

2012-01-10T22:00:00.000-08:00

Fibroma is a benign tumour of connective tissue that occurs in the oral cavity..

Clinical features:

The fibroma appears as an elevated lesion of normal colour with a smooth surface and a sessile or peduculated base.The tumour may be small or may range up to several centimeters in diameter.The tumour sometimes becomes irritated and inflammed and may show superficial ulceration.The tumour is a well defined,slowly growing lesion and occurs at any age but it commonly seen in the third,fourth and fifth decades.The tumour originates on the gingiva,buccal mucosa,tongue,lips and palate.The consistency of the fibroma may be firm and resilient or soft and spongy..The terms’ hard firoma’ and ‘soft fibrom’ are clinically used.

Histologic features:

The firoma consists of bundles of interlacing collagenous fibers interspersed with varying numbers of fibroblasts or fibrocytes and small blood vessels.The surface of the lesion is covered by a layer of stratified squamous epithelium which shows shortening and flattening of the rete pegs..If any trauma has occurred to the tissue,vasodilatation,edema and inflammatory cell infiltration are present..Areas of focal or diffuse calcifications and even ossifications are seen..These lesions have sometimes been called “Peripheral ossifying fibroma”,”ossifying fibroid epulis”,”Peripheral cementifying fibroma” or “Peripheral odontogenic fibroma”.

Treatment and Prognosis:

The treatment for fibroma is conservative surgical excision..The lesion doesnot recur..

Peripheral ossifying fibroma

2012-01-10T21:59:00.000-08:00

Peripheral ossifying fibroma has a high degree of cellularity and dystropic calcification. Peripheral ossifying fibroma occurs on the gingiva and may contain oxytalan fibres..

Clinical features:

Peripheral ossifying fibroma ocurrs at any age and is seen commonly in children and in young adults.It shows a predilection in females by a ratio ranging from 2:1 to 3:2..Equally seen in the maxilla and the mandible..It is a well demarcated focal mass of tissue on the gingiva with a sessile or peduculated base.It is of the same colour as normal gingiva or slightly reddened.The surface may be intact or ulcerated.It most commonly originates from the interdental papilla.

Roentgenographic features:

There is no apparent underlying bone involvement visible on the roentgenogram.There is a superficial erosion of the bone.

Histologic features:

There is an ulcerated layer of stratified squamous epithelium.The cellular mass consists of large numbers of plump proliferating fibroblasts throughout a very delicate fibrillar stroma.Several forms of calcification occurs in this lesion.The calcification may be in the form of single or multiple interconnecting trabeculae of bone or osteoid.There are also multinucleated giant cells found sometimes.

Treatment and prognosis:

The lesions must be surgically excised and extraction of adjacent teeth are done if need arises.

Torus mandibularis

2012-01-10T21:57:00.000-08:00

Torus mandibularis is an exostosis or outgrowth of bone found on the lingual surface of the mandible.It is a benign condition.

Clinical features:

Torus mandibularis occurs above the mylohyoid line opposite to the bicuspid teeth.It may vary considerably in size and shape.The mandibular tori are usually bilateral.The unilateral and bilateral protuberances may be single or multiple and frequently visible on dental periapical roentgenograms.

Treatment and prognosis:

Surgical removal of the torus mandibularis may be necessary because of the difficulties encountered in attempting to construct a denture over the outgrowth.

Torus palatinus

2012-01-10T21:55:00.001-08:00

Torus palatinus is a slow growing flat-based bony protuberance which occurs in the midline of the hard palate..Seen in hereditary conditions and also thought to follow a mendelian pattern.

Clinical features:

Shows predilection in females..Found at any age but shows predominance just before 30 years.It is seen as an outgrowth in the midline of the palate.It is flat,spindle-shaped,nodular or lobular.The mucosa overlying the torus is intact and may appear blanched.It can become ulcerated if traumatised.The torus may be composed of dense compact bone or of a shell of compact bone with a center of cancellous bone and so is visible on an intraoral roentgenogram.

Treatment and Prognosis:

It is a benign and never becomes malignant.When condition becomes impossible or impractical to construct a full or partial denture,then in such conditions the torus is removed surgically before the construction of the prostheses.

Hyperpituitarism - Gigantism - Acromegaly

2011-12-20T05:00:00.000-08:00

Hyperpituitarism is an increase in the number of granules in the acidophilic cells or an adenoma of the anterior lobe of the pituitary and is associated with gigantism or acromegaly..If the increase occurs before the epiphyses of the long bones are closed,gingantism results and if the increase occurs later in life,acromegaly occurs..

Clinical features:

Gigantism is characterised by a general symmetric overgrowth of the body.Persons affected are over 8 feet and show genital underdevelopment and excessive perspiration and also complain of headache,lasstude,fatigue,muscle and joint pains and hot flashes.The teeth in gigantism are proportional to the size of the jaws and the rest of the body.The roots may be longer than normal.

Acromegaly is a rare disease in which there is hypersecretion by the anterior lobe.Affected persons suffer from temporal headaches,photophobia and reduction in vision.The terminal phalanges of the hands and feet become large.The ribs also increase in size.The lips become thick and negroid.The tongue also becomes enlarged.The mandible undergoes accelerated condylar growth and hence becomes large.Thus the resulting prognathism may be extreme.The teeth in the mandible are usually tipped to the buccal or labial owing to the enlargement of the tongue.

Hypothyroidsm

2011-12-20T04:59:00.000-08:00

Hypothyroidsm

A failure of thyrotropic function on the part of the pituitary gland or an atropy or destruction of the thyroid gland leads to produce sufficient hormone to meet the requirements of the body.If this occurs in infancy,cretinism results.If it happened in adults,it is called myxedema.

Clinical features:

Congenital hypothyroidsm leads to mental defects,retarded somatic growth and generalised edema.The skull is shortened.There is a retraction of the bridge of the nose which leads to flaring.The face is wide and fails to develop longitudinally.The mandible is underdeveloped and the maxilla is overdeveloped.The hair is sparse and brittle.The fingernails are brittle and sweat glands are atropic.The tongue is enlarged and the rate of eruption of teeth is delayed.

In myxedema the swelling is extravascular.The extracellular accumulation of water and protein in the tissues.This protein has a greater osmotic effect than the serum proteins and causes an increase in the bloos protein concentration and decreased plasma volume.The lips,nose,eyelids and suborbital tissues are edematous and swollen.The tongue is large and edematous and it interferes with speech.

Chronic diffuse sclerosing osteomyelitis

2011-12-19T04:48:00.001-08:00

Chronic diffuse sclerosing osteomyelitis is a proliferative reaction of the bone to a low-grade infection.The portal of entry for the infection is not through a carious lesion but rather through a periodontal disease.

Clinical features:

Chronic diffuse sclerosing osteomyelitis may occur at any age but it is commonly seen in older persons..It is predominantly seen in edentulous mandibles and in edentulous areas..The onset of the disease is sudden without any clinical indications.Sometimes there is an acute exacerbation of the dormant chronic infection which results in mild suppuration with a spontaneous formation of a fistual opening on to the mucosal surface to establish drainage.Patients under such conditions will suffer from vague pain and a bad taste in the mouth.

Roentgenographic features:

Chronic diffuse sclerosing osteomyelitis lesions may be extensive and is often bilateral.Both maxilla and mandible are involved in some cases.The border between the sclerosis and normal bone is often indistinct.The pattern may also mimic osteitis deformans or Paget’s disease of the bone..A cotton-wool appearance is seen.

Histologic features:

Dense irregular trabeculae of bone bordered by an active layer of osteoblasts is seen.A mosaic pattern which shows repeated periods of resorption followed by repair.The soft tissue between the individual trabeculae is fibrous and shows proliferating fibroblasts and occasional small capillaries as well small focal collections of lymphocytes and plasma cells.Polymorphonuclear leukocytes may be present.In some lesions the inflammatory component is burned out leaving only sclerotic bone and fibrosis.

Treatment and prognosis:

Chronic diffuse sclerosing osteomyelitis lesions are too extensive to be removed surgically.Antibiotic adminstration is given in case of acute episodes.The lesion doesnot casue any complications though it is slowly progressive..

Chronic focal sclerosing osteomyelitis

2011-12-19T04:34:00.000-08:00

Chronic focal sclerosing osteomyelitis is an unusual reaction of bone to infection occuring in high tissue resistance or in low-grade infection.

Clinical features:

Chronic focal sclerosing osteomyelitis is seen in young persons before the age of 20 years.The tooth most commonly involved is the mandibular first molar..There may be just a large carious lesion involved.There may not be any other signs or symptoms other than mild pain associated with an infected pulp.

Roentgenographic features:

A well circumscribed radiopaque mass of sclerotic bone surrounding and extending below the apex of one or both roots.The entire root outline is nearly always visible.This helps in its distinction from benign cementoblastoma.The border of this lesion is smooth and distinct or appear to blend in to the surrounding bone.

Histologic features:

A dense mass of bony trabeculae with little interstitial marrow tissue is present.If interstitial tissue is present it is generally fibrotic and infiltrated only by small numbers of lymphocytes.Osteoblastic activity may have completely subsided at the time of microscopic study.

Treatment and prognosis:

The tooth involved in this lesion may be endodontically treated or extracted as the pulp of the tooth is infected and the infection has spread past the periapical area.The sclerotic bone that remains even after the removal of the involved tooth need not be removed surgically unless a symptomatic need arises..

Scarlet fever - Strawberry tongue - Raspberry tongue

2011-12-11T00:57:00.001-08:00

Scarlet fever is caused by bacterial infection.It is a disease that occurs in children during the winter months.Streptococcal organisms of the beta hemolytic type causes this scarlet fever.It is similar to acute tonsillitis and pharyngitis caused by streptococci..Only the nature of the toxin involved heps in differentiating the condition..Erythrogenic toxin is seen in scarlet fever.

Clinical features:

After entering through the pharynx there is an incubation period of three to five days after which the patient exhibits sever pharygnitis and tonsillitis followed by headache,chills,fever and vomiting.There is also enlargement and tenderness of the regional lymphnodes.Diffuse,bright and scarlet skin rashes appear on the second or third day of the onset of the disease..This rash is seen in areas of the skin folds and is a result of the toxic injury to the vascular endothelium which produces dilatation of the small blood vessels and hyperemia.

Oral manifestations:

The most characteristic feature seen is referred to as stomatitis scarlatina.The mucosa of the palatemay appear congested and throat is fiery red.The tonsils and faucial pillars are swollen and covered with a grayish exudate.The tongue exhibits a white coating and the fingiform papillae are edematous and hyperemic projecting above the surface as small knobs..This is termed as “Strawberry tongue”..The coating of the tongue is soon lost beginning at the tip and lateral margins and then the tongue becomes deep red,glistening and smooth except for the swollen and hyperemic papillae..This condition is termed as ”Raspberry tongue”..Ulceration of the buccal mucosa and palate may also be seen in cases of sever cases and also in cases of secondary infection.Desquamation of the skin which occurs within a week..

Complications:

Peritonsillar abcess,rhinitis,sinusitis,otitis media,mastoiditis,meningitis,pneumonia,glomerulonephritis,rheumatic fever and arthritis are the complications seen.

Treatment:

Adminstration of antibiotics will help in controlling the disease..

Benign lymphoepithelial lesion - Mikulicz’s disease

2011-12-11T00:55:00.001-08:00

Mikulicz’s disease or Benign lymphoepithelial lesion exhibits both inflammatory and neoplastic characteristics..It is an autoimmune disease in which the patient’s own salivary gland tissue becomes antigenic..

Clinical features:

Benign lymphoepithelial lesion is seen as a unilateral or bilateral enlargement of the parotid and or submaxillary glands.It is characterised by mild local discomfort,occasional pain and xerostomia.The onset of the lesion is associated with fever,upper respiratory tract infection,oral infection,tooth extraction and other local inflammatory disorders..There is a diffuse,poorly outlined enlargement of the salivary gland..These enlargements vary in size but are usually of a few centimeters in size.The duration of the tumour mass may be just a few days or many years.Lacrimal glands also may be enlarged.

Histologic features:

The disease is charcaterised by lymphocytic infiltration of the salivary gland tissue,destroying or replacing the acini.The lymphoid element is diffuse but germinal centers are occasionally only present.The epithelium may consist of ducts showing cellular proliferation and loss of polarity or as the disease persists may show solid nests or clumps of poorly defined epithelial cells termed as epimyoepithelial islands.Sometimes these cells form a syncytium.In advanced lesions there is a deposition of eosinophilic,hyaline material in the epithelial islands.

Treatment and Prognosis:

The Benign lymphoepithelial lesion can be treated by surgical excision and radiation.In mild cases there is no treatment done as the swelling may regress on its own..Only persistent lesions are treated surgically..

Dead tracts

2011-12-11T00:52:00.001-08:00

Dead tracts in dentin are seen in ground sections of teeth and are manifested as a black zone by transmitted light but as a white zone by reflected light.This optical phenomenon is due to differences in the refractive indices of the affected tubules and normal tubules.The nature of the change in the affected tubules is not known,although these tubules are not calcified and are permeable to the penetration of dyes

Bacal cell adenomas

2011-12-10T22:18:00.001-08:00

Bacal cell adenomas occur primarily in the major salivary glands particularly the parotid gland..

Clinical features:

The tumours are usually painless and are characterised by slow growth…There is a 5:1 male predilection and the majority of the patients are over 60 years of age..The tumours can occur in young persons also.The basal cell adenoma has been seen in the submaxillary gland of a new born male..Basal cell adenomas have been seen in the upper lip of elderly persons too..

Histologic features:

Basal cell adenomas have a fairly well defined connective tissue capsule.The cells are isomorphic and basaloid in appearance with basophilic round to oval nuclei.Cytoplasm is scanty and ill-defined.The tumour cells are arranged in solid nests with the peripheral cells often showing a palisaded arrangement.The tumour cells bear similarity to secretory cells of the intercalated duct.

Treatment and Prognosis:

The tumour is treated by excision and recurrences are seldom.

Canalicular adenoma

2011-12-10T22:17:00.001-08:00

The canalicular adenoma is a distinctive variant of the monomorphic adenoma..

Clinical features:

This lesion originates primarily in the intraoral accessory salivary glands and in the upper lip.Lesions also occur in the palate,buccal mucosa and lower lip.The tumour occurs in patients over 60 years of age but there is a no particular sex predilection.The tumour presents as a growing,well circumscribed,firm nodule particularly in the lip and it is not fixed and it may be moved through the tissue for some distance..

Histologic features:

The canalicular adenoma is composed of long strands or cords of epithelial cells arranged in a double row and showing a party wall.Cystic spaces of varying sizes are enclosed by these cords.These cystic spaces are usually filled with an eosinophilic coagulum.The supporting stroma is loose and fibrillar with delicate vascularity.The cells are columnar and small basal cells resemble salivary gland excretory ducts.The tumour does not show show any multilayered basal lamina.

Treatment and prognosis:

The tumour can be treated by enucleation or simple surgical excision..Recurrence is rare..

Myoepithelioma

2011-12-10T22:15:00.001-08:00

The myoepithelioma is an uncommon salivary gland..

Clinical features:

It occurs in adults with an equal sex distribution.The parotid gland is most commonly involved..It occurs frequentli in the palate..

Histologic features:

The tumour is composed of spindle shaped or plasmacytoid cells or a combination of the two cell types.The tumour is difficult to diagnose definitively at the light microscopic level.Definitive diagnosis lies in the ultrastructural identification of myoepithelial cells.The myoepithelial cell exhibits a basal lamina and fine intracytoplasmic myofilaments.Desmosomes are encountered between adjacent cells.

Treatment and prognosis:

The tumour is treated by surgical excision.

Uses of Panoramic radiography

2011-11-20T05:42:00.001-08:00

Panoramic radiography:

Uses:

1.For visualising the maxilla and the mandible in one film.

2.For patient education.

3.To evaluate impacted teeth.

4.In the evaluation of multiple unerupted supernumerary teeth.

5.To evaluate eruption sequence and pattern,growth and development.

6.To detect any pathology involving the jaws.

7.To examine the extent of a large lesion.

8.To evaluate traumatic injuries.

9.For patients with limited mouth opening.

10.To identify diseases of the temperomandibular joint.

11.In the evaluation of styloid process.

Use of radiographs in the diagnosis of periodontal disease

2011-11-20T05:38:00.001-08:00

Radiographs play a vital role in the diagnosis of periodontal disease in the identification of the following initiating factors and status of the periodontium...Below are the uses..

-Identifying calculus

-Identifying overextended restorations

-Identifying poorly contoured restorations

-Determining occlusion

-Determining the root length

-Determining the morphology of the roots

-Determining the crown-root ratio

-Determining the width of the periodontal ligament space

-Evaluation of the condition of the alveolar bone

-Evaluation of the extent of bone loss

-Identification of the furcation involvement

-Evaluation of the number of teeth involved

-Determining the pattern of bone loss

-Determining the location and proximity of the maxillary sinus

-Evaluation of the status of the adjacent teeth

-For treatment planning

Radiographic features of fracture of the teeth

2011-11-18T09:41:00.001-08:00

Radiographic features of fracture of the teeth:

-Radiolucent line between tooth segments

-Displacement of tooth fragments

-Disruption of the continuity of the tooth surface

-in case of root fracture,there may be a radiolucent line transversing the midportion of the tooth

-Oblique fracture line may be mistaken for two fracture lines as radiographically the radiographically the radiolucent lines may be evident seperately in two planes

Orthopantomogram

2011-11-18T09:38:00.001-08:00

An Orthopantomogram(OPG),also known as an “orthopantogram” or “Penorax” is a panoramic scanning dental x-ray of the upper and lower jaw.It shows a two dimensional view of a half circle from ear to ear.

Dental panoramic radiography equipment consists of a horizontal rotating arm which hold an x-ray and a moving film mechanism arranged at opposed extremities.

The collimation of the machine means that,while rotating,the x-ray projects only a limited portion of anatomy on to the film at any given instant but as rotation progresses around the skull ,a composite picture of the maxillo-facial block is created.

Dental x-ray technology has also been moved from conventional film to digital x-ray technology.One particular type of digital CR system uses a photostimulable phosphor plate in place of film.The other types of digital imaging technologies use electronic sensors and computer.

Advantages of panaromic images:

1.Broad coverage of facial bones and teeth

2.Low patient radiation dose

3.Convenience of examination for the patient as films need not be placed inside the mouth

4.Ability to be used in patients who cannot open the mouth oe when the opening is restricted eg.due to trismus

Diagnostic uses:

1.Helpful in the diagnosis and treatment planning of impacted wisdome teeth.

2.Periapical involvement and periodontal bone loss can also be diagnosed.

3.Finding the source of dental pain.

4.Assessment for the placement of dental implants.

5.For pre and post operative orthodontic assessment.

The most common use is to determine the status of wisdom teeth and trauma to the jaws.

Bennett’s classification of fracture of teeth

2011-11-18T09:36:00.001-08:00

Bennett’s classification of fracture of teeth

Class I: Traumatised tooth without coronal or root fracture

A.Tooth firm in alveolus

B.Tooth subluxed in alveolus

Class II: Coronal fracture

A.Involving enamel

B.Involving enamel and dentin

Class III: Coronal fracture with pulpal exposure

Class IV: Root fracture

A.Without coronal fracture

B.With coronal fracture

Class V: Avulsion of tooth

Classification of elongated styloid process

2011-11-18T09:34:00.001-08:00

Elongated styloid process is classified as follows:

Classification of elongated styloid process based on the appearance:

A.i.Slightly elongated.

ii.Crooked.

iii.Segmented.

iv.Very elongated.

B.Type I – Elongated.

Type II – Pseudoarticulated.

Type III – Segmented.

C.Based on the pattern of calcification

i.A calcified outline.

ii.Partially calcified.

iii.A nodular complex.

iv.Completely calcified.

Disadvantages of Panoramic radiography on dentistry

2011-11-18T09:31:00.001-08:00

Here are a few disadvantages of Panoramic radiography:

1.Images in a panoramic film are not as sharp as in an intraoral film.

2.Panoramic radiography cannot be used in the diagnosis of caries.

3.Panoramic radiography cannot be used in the evaluation of bone loss due to periodontal disease.

4.Panoramic radiographic image shows superimposition in the premolar region.

5.Structures in the anterior region may not be well defined.

6.Structures outside the image layer connot be visualised.

7.Panoramic radiography cannot be used as a sustitute for intraoral film.

Limitations of radiographs in dentistry

2011-11-18T09:22:00.001-08:00

Here are some limitations of radiograph:

1.Radiographs cannot be used in the diagnosis of severe infections confined to the gingiva

2.Initial bone changes may not be apparent in the radiograph

3.Superimposition of buccal and lingual bone makes it difficult to determine the bone loss

4.The dense image of the roots superimposed obscures the height of the bone

5.Soft tissue and hard tissue relationship cannot be determined

6.Radiographically it may not be possible to differentiate between a diseased state and successfully treated case

7.The actual extent of bone destruction may be more than what is visualized in the radiograph

Fracture of the teeth

2011-11-18T09:20:00.001-08:00

Fracture of the tooth is defined as the breaking of tooth parts..The maxillary incisors are more prone for fracture especially in those individuals with proclined anterior teeth.Children are more prone to traumatic injuries.

Coronal fractures of teeth can be classified in to:

1.Fractures involving only the enamel and without any loss of tooth structure(crack)

2.Fracture involving the enamel or the enamel and the dentin with loss of tooth structure and without involvement of the pulp(uncomplicated fracture)

3.Fractures involving the enamel,the dentin and the pulp with loss of tooth structure(complicated fracture)

Requirements of a space maintainer

2011-10-08T05:43:00.000-07:00

A space maintainer should fulfill the following requirements:

1.It should maintain the entire mesio-distal space created by a lost tooth

2.It must restore the function as far as possible and prevent over-eruption of opposing teeth

3.It should be simple in construction

4.It should be strong enough to withstand the functional forces

5.It shouldnot exert excessive stress on adjoining teeth

6.It must permit maintainance of oral hygiene

7.It must not restrict normal growth and development and natural adjustments which take place during transition from deciduous to permanent dentition

8.The space maintainer shouldnot come in the way of other functions

Classification of space maintainers

2011-10-08T05:37:00.000-07:00

Space maintainers have been classified by various authors as follows:

According to Hitchcock:

1.Removable or fixed or semi-fixed

2.With bands or without bands

3.Functional or non-functional

4.Active or passive

5.Certain combinations of the above

According to Raymond C.Thurow

1.Removable

2.Complete arch

Lingual arch

Extra-oral anchorage

3.Individual tooth

According to Hinrichsen:

1.Fixed space maintainers:

Class I a)Non-functional types

i)Bar type

ii)Loop type

b)Funtional types

i)Pontic type

ii)Lingual arch type

Class II - Cantilever type(distal shoe,band and loop)

2.Removable space maintainers:

Acrylic partial dentures

Preventive orthodontics

2011-10-08T05:29:00.000-07:00

Preventive orthodontics is that part of orthodontic practice which is concerned with the patient's and patient's education,supervision of the growth and development of the dentition and the cranio-facial structures,the diagnostic procedures undertaken to predict the appearance of malocclusion and the treatment procedures instituted to prevent the onset of malocclusion..

The following are some of the procedures undertaken in preventive orthodontics:

1.Patient education

2.Caries control

3.Care of deciduous dentition

4.Management of ankylosed tooth

5.Maintenance of quadrant wise tooth shedding time table

6.Checkup for oral habits and habit breaking appliance if necessary

7.Occlusal equilibriation if there are any occlusal prematurities

8.Prevention of damage to occlusion.eg.Milwaukee braces

9.Extraction of supernumerary teeth

10.Space maintenance

11.Management of deeply locked first permanent molar

12.Management of abnormal frenal attachments

Growth spurts

2011-09-26T04:39:00.000-07:00

Growth does not take place uniformly at all times..There seems to be periods when a sudden acceleration of growth occurs..This sudden increase in growth is termed "Growth spurt"
The physiological alteration in hormonal secretion is believed to be the cause for such accentuated growth..The timing of the growth spurts differ in boys and girls..

The following are the timings of growth spurts:

a)Just before birth

b)One year after birth

c)Mixed dentition growth spurt

Boys:8-11 years

Girls:7-9 years

d)Pre-pubertal growth spurt

Boys:14 to 16 years

Girls:11 to 13 years

Growth modification by means of functional and orthodontic appliances elicit better response during growth spurts..Surgical correction involving maxilla and mandible should be carried out only after the cessation of the growth spurts..

Interdental cleaning aids

2011-09-16T22:49:00.000-07:00

Interdental aids are adjunctive devices which are used to remove plaque from the interproximal tooth surfaces
The toothbrush is an excellent device for plaque removal on surfaces which are accessible..However it is not adequate for interproximal cleaning..Thus special efforts have to be made and special devices have to be used for the removal of plaque from the inter-dental areas,especially of posterior molars..

Factors in selection of an interdental cleaning aid:

-Type of gingival embrasures

-Alignment of teeth

-Fixed prosthesis or orthodontic appliances

-Open furcation areas

-Contact areas

Abrasion of the teeth

2011-09-16T22:43:00.000-07:00

Abrasion is the loss of tooth substance produced by mechanical wear other than by mastication or it may be defined as the pathologic wearing away of tooth substance through some abnormal mechanical process..
Contributing factors:

-Hard toothbrush

-Horizontal brushing

-Excessive pressure during brushing

-Abrasive agent in the dentifrice

-Prominence of the tooth surface labially or buccally

Location of abraded areas:

-Facial surfaces of canines,premolars and sometimes first molars or any tooth in bucco- or labioversion,those most available to pressure of the toothbrush..The canines are most susceptible because of their prominence on the curvature of the dental arches

-Most abraded areas are on the cervical areas of exposed root surfaces but occasionally may occur on enamel

Appearance:

Saucer shaped or wedge shaped indentations with smooth shiny surfaces are seen

Corrective measures:

-Explain the problem to the patient to assure full cooperation

-Advise a specific toothbrush with soft textured bristles or filaments

-Change the toothbrushing techniques

-Recommend a less abrasive dentifrice

-Use a smaller amount of the dentifrice or toothpaste

Effects of improper tooth brushing

2011-09-16T22:22:00.000-07:00

Here are some of the effects of improper tooth brushing:

1.Toothbrush trauma:Gingival alterations

A.Acute alterations:

1.Scuffled epithelial surface with denuded underlying connective tissue

2.Punctate lesions that appear as red pin point spots

3.Diffuse redness and denuded attached gingiva

Precipitating factors:

1.Horizontal or vertical scrubbing tooth method with pressure either manual or powered

2.Over vigorous placement and application of toothbrush

3.Penetration of gingiva by filament ends

4.Use of toothbrush with frayed,broken bristles or filaments

5.Application of filaments beyond attached gingiva

B.Chronic alterations:

1.Usually appear on the facial gingiva because of the vigour with which the toothbrush is used

2.Areas most commonly involved are around canines or teeth in labio- or bucco- version

3.It is inversely proportional to the right or left-handedness of the patient

Recession:

1.Appearance: margin of the gingiva has receded towards the apex and the cementum is exposed

2.Predisposing anatomic factors:

i.malposition of teeth

ii.narrow band of attached gingiva cannot withstand pressures of brushing

Changes in gingival contour:

1.Rolled,bulbous,hard,firm marginal gingiva in 'piled up' or festoon shape

2.Gingival cleft

Precipitating factors:

4.Repeated use of vigorous rotary,vertical or horizontal toothbrushing techniques over a long period of time

5.Use of long,brisk strokes with excessive pressure over a long period of time

6.Habitual prolonged brushing in one area

7.Excessive pressure applied with worn out non-resilient brush

Suggested corrective measures:

-Use of a softer toothbrush

-Demonstration of proper toohbrushing technique

ADA Specification of a toothbrush

2011-09-02T02:00:00.000-07:00

Brushing surface:

-1 to 1.25 inches in length

-5/16 to 3/8 inches in width

-2 to 4 rows of bristles

-5 to 12 tufts

Manual toothbrushes are designed to reach and efficiently clean most areas of the oral cavity..Whatever be the design of the toothbrush,the fact is that the user is the only one responsible for using any toothbrush most efficiently..

Conventional toothbrushes may be modified in order to achieve enhanced plaque removal..Eg..modifications to the configuration of the handle grip,the head and bristles..

The handle may be curved or angled for improved comfort by the user..The bristles may differ in number of tufts,rows or shapes,as they may be rounded,flat ended,v-shaped and so on..Toothbrushes may also be double and triple headed.The rounded bristles reduces trauma from improper brushing..

Toothbrush modifications:

Long and contoured handles

Double angulation of the handle and neck

Toothbrush head modifications:

Concave surface

Deep grooved design

Conventional flat multitufted

Special indicator bands

Parts of a toothbrush

2011-09-02T00:23:00.000-07:00

Have discussed parts of a toothbrush below..

Handle:The part grasped in the hand during toothbrushing..

Head:The working end of a toothbrush that holds the bristles or filaments..

Tufts:Clusters of bristles or filaments..

Brushing plane:The surface formed by the free ends of the bristles or filaments..

Shank:The section that connects the head and the handle...

A toothbrush consists of a handle and a head connected by a neck..The bristles with or without rounded ends are arranged in rows and follows a particular pattern according to brush design...

While choosing a brush,the size of the head must be chosen wth care..The head must be small enough for maximum maneuverability in the oral cavity..The head thus shouldnot be no longer than 13/8" in adult brushes,1" or less in children and to be no wider than 1/2 inch in adult and 5/6" in children's brushes..The handle of a toothbrush is a matter of individual preference..It should be long enough to fit in the palm of the hand...Straight handles are more common...Handles with contrangle may provide the brushes with a better sense of touch...

Ideal tooth brush characteristics

2011-09-02T00:04:00.000-07:00

An ideal toothbrush should have the following:

-It should confirm to individual patient requirement in size,shape and texture..

-Be easily and effectively manipulated..

-Be easily cleaned and aerated,impervious to moisture...

-Be durable and inexpensive..

-Be designed for utility efficiency and cleanliness..

Modified stillman's technique

2011-08-08T22:07:00.000-07:00

Modified stillman's technique is another method of tooth brushing and widely followed by many people...

Indications:

-Dental plaque removal from cervical areas below the height of contour of the enamel and from exposed proximal surfaces

-General application for cleaning tooth surfaces and massage of the gingiva

-Recommended for cleaning in areas with progressing gingival recession and root exposure to prevent abrasive tissue destruction

Technique:

The bristles are pointed apically with an oblique angle to the long axis of the tooth..

The bristles are positioned partly on the cervical aspects of the teeth and partly on the adjacent gingivae..

The bristles are activated by short back and forth motions and simultaneously moved in a coronal direction..

Following 20 strokes,the procedure is repeated systematically on adjacent teeth..

A soft toothbrush is indicated for this technique..

Disadvantages:

1.Time consuming

2.Improper brushing can damage the epithelial attachment

Modified bass technique

2011-08-08T21:58:00.000-07:00

Modified bass technique is another method of tooth brushing...

Indications:

1.As a routine oral hygeine measure

2.Intrasulcular cleansing

Technique:

This technique combines the vibratory and circulatory movements of the Bass technique with the sweeping motion of the Roll technique..

The toothbrush is held such that the bristles are at 45 degrees to the gingivae..

Bristles are gently vibrated by moving the brush handle in a back and forth motion..

In a single motion,the bristles are then swept over the sides of the teeth towards their occlusal surfaces..

Advantages:

-Excellent sulcus cleaning

-Good interproximal and gingival cleaning

-Good gingival stimulation

Disadvantages:

Moderate dexterity of wrist is required
　

Objectives of toothbrushing

2011-08-07T00:10:00.001-07:00

Objectives of toothbrushing:

1.To clean the teeth and interdental spaces of food remnants,debris and stains,etc

2.To prevent plaque formation

3.To disturb and remove plaque

4.To stimulate and massage gingival tissue

5.To clean the tongue

Advantages of powered toothbrushes

2011-08-07T00:09:00.000-07:00

Advantages of powered toothbrushes

1.It increases patient motivation resulting in better patient compliance

2.Increased accessibility in interproximal and lingual tooth surfaces

3.No specific brushing technique required

4.Uses less brushing force than normal toothbrushes

5.Brushing timer is incorporated in some brushes to help the patient in brushing for the required duration

Ionic toothbrushes

2011-08-07T00:07:00.001-07:00

Ionic toothbrushes change the surface charge of a tooth by an influx of positively charged ions..The plaque with a similar charge is thus repelled from the tooth surface and is attracted by the negatively charged bristles of the toothbrush..However the efficacy of these brushes have not been proved so far..

Sonic and ultrasonic toothbrushes

2011-08-07T00:02:00.001-07:00

These types of toothbrushes produce high frequency vibrations(1.6 MHz) which lead to the phenomenon of cavitation and acoustic micro streaming...This phenomenon aids in stain removal as well as disruption of the bacterial cell wall

Charter's method of brushing

2011-07-26T00:32:00.000-07:00

Indications:
-Individuals having open inter dental spaces with missing papilla and exposed root surfaces

-Those wearing F.P.D. or orthodontic appliances

-For patients who have had periodontal surgery

-Patients with moderate recession paticularly interproximally

-Massage and stimulation for marginal and interdental gingiva

Technique:

A soft or medium multitufted tooth brush is indicated for this technique..

Bristles are placed at an angle of 45 degrees to the gingivae with the bristles directed coronally..

The bristles are activated by mild vibratory strokes with the bristle ends ying interproximally..

Disadvantages:

1.Brush ends do not engage the gingival sulcus to remove subgingival bacterial accumulations

2.In some areas the correct brush placement is limited or impossible,therfore modifications become necessary which add to the complexity of the procedure

3.Requirements in digital dexterity are high

Scrub's method of brushing

2011-07-26T00:28:00.000-07:00

The scrub brush method requires vigorous horizontal,vertical and circular motions..It is the virtual free style of the brushing scene..

Disadvantages:

-Ineffective at plaque removal

-Tooth abrasion and gingival recession

-Detrimental to general oral health

Methods of using dental floss

2011-07-15T19:47:00.000-07:00

There are two methods of using dental floss..They are
1.The spool method used by adults and teenagers with mental maturity

2.The circle and loop method used by handicapped and metally retarded patients

1.Spool method:

About 45 cms long floss is taken and about 10 cms from each end is wound around the middle finger of each hand..

In both the hands the last three fingers are folded and closed and both the hands are moved apart..

In this way about 5 cms long floss is held between the index fingers of both the hands..

2.Circle or loop method:

In this a loop or circle of the floss is made from about 45 cmc long piece and both the ends are tied securely with the three knots..

All the fingers except the thumbs of both the hands are placed within the loop and the floss is held by both the hands having about 2.5 cms floss between fingers of both the hands..

Fones method or circular scrub method - Brushing method for children

2011-07-15T17:26:00.000-07:00

Fones method or circular scrub method

Indication:

Indicated for young children who want to do their own brushing but do not have the muscle development for techniques which require more co-ordinations

Technique:

The child is asked to stretch his or her arms such that they are parallel to the floor..

The child is then asked to make big circles using the whole arm to draw circles in the air..

The circles are reduced in diameter until very small circles are made in front of the mouth..

The child is now ready to make circles on the teeth with the toothbrush,making sure that the teeth and gums are covered..

Advantages:

1.This technique has equal or better potential than Bass technique for plaque removal and prevention of gingivitis

2.It is easy to learn

3.It requires only shorter time

4.Can be used by physically handicapped individuals as well

5.Can also be used by patients who lack dexterity for a more technical brushing method

6.Gingiva is provided with good stimulation

Disadvantages:

1.There can be a possible trauma to the gingiva

2.Interdental areas are not properly cleaned

3.It is detrimental for adults especially who use the brush vigorously

Ideal requisites of an antiplaque agent:

2011-07-15T17:13:00.000-07:00

Ideal requisites of an antiplaque agent:

1.Should significantly reduce plaque and gingivitis

2.Should prevent growth of pathogenic bacteria

3.Should prevent development of resistant bacteria

4.Should be compatible with the oral tissues

5.Should not stain teeth or alter taste

6.Should exhibit good retentive properties

7.Should be inexpensive and easy to use

Tooth movements possible using fixed appliances

2011-07-12T00:45:00.000-07:00

More than one type of tooth movement can be brought about by using fixed appliances:
Tipping:

Tipping is the simplest type of tooth movement,produced by the application of a single force on the tooth crown.As a result,the crown moves in the direction of the force around a fulcrum in the apical region of the root..The root apex experiences a counter-reaction and moves in the opposite direction.Tipping type of tooth movement can be used to treat only certain malocclusions.Most fixed appliances are capable of producing tipping..

Bodily movement:

Bodily tooth movement implies an equal movement of both the crown as well as the root in the same direction..Certain fixed appliances are capable of bodily movement..

Torquing:

Torquing implies root movements in the labial or lingual direction.It is possible to move the roots in a labial or lingual direction using fixed appliances.

Uprighting:

Uprighting refers to mesio-distal movement of the roots.Finer detailing of the roots by moving them mesio-distally can be brought about by fixed appliances.

Rotations:

Teeth that are rotated around their long axes can be derotated using fixed appliances.The dgree of rotational control possible with fixed appliances is not possible with removable appliances.

Extrusion and intrusion:

Extrusion and intrusion refers to vertical movements of teeth along their long axis.Extrusion and to a lesser extent intrusion of teeth or groups of teeth is possible using fixed appliances.

Seperators in fixed appliances

2011-07-12T00:40:00.000-07:00

In many patients the presence of a tight inter-dental contact results in difficulties during banding.While attempting to pass a band through the inter-dental contact,the band tend to get distorted.In addition the patient may experience some amount of discomfort.The teeth should therefore be seperated to break the tight inter-dental contact.This is achieved using the various types od seperators...

Brass wire seperators:

Soft brass wire of 0.5 or 0.6 mm diameter is passed around the contact and the ends are twisted tightly together.The end is cut short and is tucked between the teeth.

Ring seperators:

They are small elastic rings that are passed through the contact using special pliers(applicator).The stretched elastic ring encircles the interdental contact and as it contracts,the teeth are seperated.

Dumbell seperators:

It is a dumbell shaped piece of elastic that is stretched and passed through the inter-dental contact.The stretched seperator tries to regain its original length and in doing so brings about seperation of teeth.

Steps in bonding - Steps involved in fixing a fixed appliance

2011-07-07T00:34:00.000-07:00

Bonding is done in the following steps:
1.The crowns of the teeth to be bonded are cleaned using pumice and bristle brush so as to remove plaque and other organic debris present on the enamel surface.

2.After thorough cleaning,the teeth are washed and dried.During the bonding procedure,adequate moisture control should be maintained by the use of saliva ejectors and cotton rolls.

3.30 - 50% phosphoric acid in gel or liquid form is used to etch enamel.This etching is usually done for 45 to 60 seconds,after which the etchant is washed off with water.The teeth are then dried and once again isolated using fresh cotton rolls.

4.Sealant is applied on to the etched enamel surface.

5.Adequate quantity of bonding adhesive is placed on the base of the brackets.The bracket is then placed on the tooth and is firmly pressed in to position.Excessive adhesive that appears as flas is removed using a scaler.

6.The bond is allowed to strengthen for a period of time before placing the arch wires.

Disadvantages of bonding

2011-07-07T00:32:00.000-07:00

Here are the disadnatages of bonding:

1.Bonded attachments are weaker than banded attachments and hence are more prone to bond failure.

2.Bonding involves etching of the enamel with an acid which may lead to enamel loss and an increased risk of demineralisation.

3.Enamel fracture can occur during debonding.

Advantages of bonding

2011-07-07T00:30:00.000-07:00

Bonding offers numerous advantages over banding which can be listed as:

1.It is esthetically superior.

2.It is faster to bond than to pinch bands around the teeth.

3.It enables maintenance of better oral hygiene.

4.It is possible to bond on teeth that have aberrant shapes or forms.It might be impossible to band such teeth.

5.It is easier to bond than band in case of partially erupted and fractured teeth.

6.The risk of caries under loose bands is eliminated.

7.Interproximal areas are accessible for restoration and proximal stripping.

Robert's retractor

2011-07-06T00:01:00.000-07:00

Robert's retractor is a labial bow made of thin gauge stainless steel wire having a coil of 3mm internal dismeter mesial to the canine..The use of thin 0.5mm diameter wire along with increased wire length due to the incorporation of a coil makes the labial bow highly flexible..

As very thin wire is used for its fabrication,the bow is highly flxible and lacks adequate stability in the vertical plane.Thus the distal part of the retractor is supported in a stainless steel tubing of 0.5 mm internal diameter.

The Robert's retractor is indicated in patients having severe anterior proclination with overjet of over 4 mm.As the bow is highly flexible it generates lighter forces.Thus they can be used in adult patients in whom lighter forces are desirable.

Reverse labial bow

2011-07-06T00:00:00.000-07:00

Reverse labial bow is also called reverse loop labial bow..Here the U loops are adapted occlusally between the first premolar and canine.As a longer span of wire is incorporated,the bow exhibits increased flexibility.Indications for use are similar to that of short labial bow.The cativation of this bow is done in two steps..First the U loop is opened...This results in lowering of the labial bow in the incisor region.A compensatory bend is then given at the base of the U loop to maintain proper level of the bow..

Mills retractor

2011-07-05T23:58:00.000-07:00

Mills retractor is a labial bow having extensive looping of the wire so as to increase the flexibility and range of action(ability to remain active over extended periods of time)

Mills retractor or extended labial bow as it is sometimes called is indicated in patients with a large overjet.The disadvantages of the Mills retractor include difficulty in construction and poor patient acceptance due to the complex design of the bow..

Syphilis of the jaw

2011-06-16T00:21:00.000-07:00

The syphilis of the jaw is rarely seen due to the number of antibiotics available.Causative organism is Treponema pallidum.The bone lesion occurs in the tertiary stage and is observed both in prenatal and acquired forms.
Commonly affected areas are cranial bones,nasal bone and hard palate.Bone lesions result from formation of gumma.The manifestations that may occur are in the form of gummatous destruction of bone or diffuse syphilitic osteomyelitis of the jaws.

Gumma is a hard painless lump of rubber like consistency in the subcutaneous tissue.When the overlying mucosa breaks down,an ulcer with a punched out appearance is formed.The base of the lesion is covered with yellow slough overlying the granulation tissue.A gumma can perforate the palate.

In diffuse syphilitic osteomyelitis,mandible is affected.The features are similar to pyogenic osteomyelitis and the two conditions are diifficult to differentiate radiologically.Pathological fractures are also seen in syphilitic osteomyelitis.

The treatment is the same as for pyogenic osteomyelitis.Broad spectrum antibiotics should be given over a long duration.

Factors responsible for acute osteomyelitis in children and adults

2011-06-16T00:14:00.000-07:00

Local factors:
a.Acute dentoalveolar abcess-The infection remains confined to the smaller area in an acute alveolar abcess with a defensive barrier of pyogenic membrane..This defensive barrier is disturbed if the causative organisma are virulent or resistance of the patient is poor or curettage or extraction is done in an acute condition..Under these circumstances infection spreads to a larger area of bone causing osteomyelitis.

b.Extensive periodontal pathology in which deep periodontal pockets are present all over the jaw can spread the infection

c.Pericoronal infection-In acute pericoronitis or pericoronal abscess,infection may be carried to the periosteum and hence bone.

d.Infective cysts and tumours can spread the infection to the jaw bone.

e.Dry socket which is a localised type of osteomyelitis following a tooth extraction can spread following curettage without an antibiotic cover.

f.In mercurial and Bismuth stomatitis the infection can lead to periostitis and osteomyelitis.

g.Infection of the ascending ramus may take place following tonsillitis.

h.In case of acute fascial infection and cellulitis..Infection can be carried to jaw bones leading to osteomyelitis.

i.Sinusitis of the maxillary sinus can lead to osteomyelitis of maxilla especially in children.

j.Trauma,especially compound fractures of the mandible,if remain untreated can get contaminated by direct invasion of the spongiosa resulting in osteomyelitis.

k.Osteomyelitis of the condyle of the mandible can develop as a sequelae to middle ear infection.

General factors:

It is mainly because of hematogenous infection where following pyaemia or septicaemia the infection gets deposited in the jaw bone leading to osteomyelitis.In children,the osteomyelitis of the jaw may occur following exanthemata,important are measles,diphtheria,chicken pox,typhoid,pertusis.

Indications for reimplantation

2011-06-14T00:11:00.000-07:00

Indications for reimplantation:

1.Teeth avulsed due to trauma when these are out of the mouth for a short period

2.When conventional endodontic treatment is not possible to be carried out within the mouth

3.When surgical endodontics is ruled out for want of access of the area

4.Periodontally diseased teeth that are excessively mobile

5.Extruded teeth on account of bone damage

6.Deciduous anteriors can be reimplanted for esthetic reasons as well as for maintennance of space

7.Teeth accidentally extracted or luxated due to improper use of elevators

8.Teeth extracted or luxated by the use of mouth-gag or laryngoscope

Storage of avulsed tooth - How to store an avulsed or fallen tooth

2011-06-14T00:09:00.000-07:00

An avulsed tooth is best stored in patient's own saliva.It is advised to wash off a contaminated tooth with water gently without touching or rubbing the root part and be kept under the tongue till the patient reports for treatment..

Alternatively,the tooth can be stored in sterilized container in ice cold normal saline or milk.The patient should always be advised to contact the dentist for reimplantation as early as possible..

classification of impacted maxillary canines

2011-06-14T00:06:00.001-07:00

Impacted maxillary canines are classified as follows:
Class I: Maxillary canine in palatal position.This can be horizontal,vertical and angulated

Class II: Labially impacted canine.It can be horizontal,vertical and angulated..In this position the crown of the impacted canine can be in intimate relationship with the incisors or well above the apices of incisors

Class III: Impacted canine with crown on the palatal side and root on the buccal side or vice versa

Class IV: Vertically impacted canine between lateral incisor and first premolar

Class V: Canine impacted in the edentulous maxilla

Class VI: Maxillary canines in unusual positions

Labial vestibuloplasty

2011-06-10T05:39:00.001-07:00

The incision for labial vestibuloplasty is placed along the depth of the sulcus and dissection is extended supra-periosteally..The raw area created is allowed to heal by epithelisation..Extended labial flange of the denture or a mould of acrylic or gutta percha is left in depth to seperate the labial and alveolar tissues..To overcome the scar contractures at times,skin or mucous membrane graft is used to cover the raw area..
A modified incision can be made by placing it in the lip mucosa to the desired length..It is extended supre-periosteally to the alveolar ridge..The vestibule is deepened and the mucosal flap is placed over the periosteum of the ridge..The end of the flap is sutured at the depth of the vestibule.The raw area on the lip is allowed to heal by epithelisation..

An alternate incision can be made on the alveolar bone slightly labial to the alveolar crest..The dissection is carried supra-periosteally in to the sulcus..The mucosal flap is sutured at the depth of the vestibule by placing it on the lip side..The raw area situated on the alveolar ridge heals by epithelisation and there are minimal chances of contraction..

The raw area can also be covered with mucosa or skin graft..The following points need careful consideration in sulcus deepening procedures:

1.It is good to provide epithelial lining on raw areas to prevent scar formation and contractures..The greater the thickness of the graft,lesser is the tendency for contracture to develop.

2.In all sulcus deepening procedures a good amount or relapse is always expected..Thus the defect must be over corrected.

3.All attachments should be properly freed and wound should never be stitched under tension.It is advisable to keep raw area on the ridge side than on the cheek side to minimise the contracture.

4.Over-extended denture flange or gutta percha mould should be kept in the defect for a couple of days post-operatively to prevent contractures.

Zygomaticoplasty

2011-06-06T06:09:00.000-07:00

Zygomaticoplasty is performed for vestibular extension of the atrophied maxilla and for the improvement of the maxillary flange height in the buttress region..A horizontal incision is made just below the base of the process..Muco-periosteum is reflected..5 to 8 mm of the alveolar height can be made by cutting the buttress with the bur or chisels..Care should be taken not to perforate the antrum..The wound can be closed by interrupted sutures after smoothening and irrigation

Lingual vestibuloplasty - Lowering the floor of the mouth

2011-06-06T06:06:00.000-07:00

Patients requiring lingual vestibuloplasty invariably report with the requirement of ridge extension on the labial side as well therefore,this procedure if often combined with the labial or buccal vestibuloplasty..A supra-periosteal incision is made at the junction of lingual mucosa and attached gingiva..The mylohyoid muscle is divided close to the bone with scissors or electro-cutting knife..Care should be taken to save submandibular gland and duct and the lingual vessels in the area..In the anterior region genioglossus muscle is partially divided,if required..After the myotomies are performed,the mucosal flaps are taken deep in to the extended vestibule and held in place with percutaneous sutures..

Excision of tori

2011-06-05T03:10:00.001-07:00

Maxillary and mandibular tori have no significance and need no surgical attention..Only excessively large tori need correction..Excision is required whenever torus interferes with insertion of the denture..

a)Torus palatinus

It varies in size and shape and is normally encountered on the midline of the hard palate..It may interfere with the insertion of a denture since a denture rocks over it and breaks over a period of time..The treatment lies in excision..

The incision is made in the midline of the palate running over the bony growth from anterior to the posterior end..The thin muco-periosteal flaps are carefully reflected..The lateral extensions of the incision can be made at the anterior and posterior end as per the requirement..The bony torus is excised with the help of burs and rongeurs by splitting it in to small segments..Torus palatinus shouldnot be excised enmass with the help of the chisel because of fear of nasal perforation..The bone is smoothened with bone file..Excess of soft tissue is trimmed for approximating the flaps..The wound is closed preferrably by continuous sutures..To prevent a hematoma formation,a bolus of sterile gauze is kept pressed against the vault of the palate with the help of sutures or wires criss-crossing the palate passed around the posterior teeth

b)Torus mandibularis

These bony protruberances are found on the lingual side of the mandibular premolars..The treatment of torus mandibularis lies in its surgical removal.The incision is made in the crest of the ridge in the premolar region.An envelope flap or triangular flap with a vertical arm placed anteriorly or posteriorly is raised.A small chisel is vertically placed at the base of the lesion along the superior border with the bevel facing the bone..A gentle tap is usually sufficient to sepearte the torus..The bone is smoothened with a bone file and the wound is closed with interrupted sutures

Pre-prosthetic surgery

2011-06-05T03:08:00.000-07:00

Pre-prosthetic surgery is aimed at providing a good healthy surface for the insertion of dentures..It also involves the surgical procedures aimed at making the best use of residual tissues in terms of restoration of function and aesthetics..It involves all surgical procedures by virtue of which a smooth,healthy U shaped ridge without any favourable undercuts or bony growths and with sufficient vestibular depth is achieved..

Requirements of an ideal ridge:

1.An ideal alveolar ridge is a U shaped ridge with parallel sides..

2.It must provide an adequate bony support for the denture..

3.It should have sufficient vestibular depth..

4.It should be covered by an adequate keratinised mucosal lining of uniform thickness..

5.It should not have any undesirable undercuts..

6.It should not have any bony protruberances..

7.It should be free from high frenal attachments,abnormal muscle attachments and scar tissue that may dislodge the denture..

8.The relationship between upper and lower ridge should be anatomically satisfactory..

Types of surgery

A.Surgery for ridge correction

B.Surgery for ridge extension

C.Surgery for ridge augmentation

Fibrous hyperplasia of maxillary tuberosity

2011-06-05T03:02:00.001-07:00

Idiopathic fibrous hyperplasia found in relation to maxillary molars is attributed to chronic periodontal pathology...It persists as thickened large tuberosity even after the teeth are extracted..This fibrous tissue renders the artificial denture unstable and needs excision..However,this fibrous hyperplasia must be differentiated from bony enlargement as the two conditions closely resemble..This can be differentiated with the help of an X-ray..

Alveolectomy

2011-06-04T00:15:00.000-07:00

Alveolectomy refers to surgical removal of the alveolar process...The attempt should be made to create an ideal U shaped ridge...The cortical alveolectomy refers to the trimming of labio-buccal alveolar bone where as inter-septal alveolectomy involves excision of interdental septa and compressing the buccal and labial cortical plates towards each other...Care should be taken not to sacrifice the alveolar height unnecessarily because the main aim of alveolectomy is to prepare a good bed for the denture and not sacrificing the denture bearing area..

The procedure is carried out after the extraction of single tooth,if the alveolar process in the adjacent teeth area is very low...An elliptical incision is made after the extraction and a muco-periosteal flap is raised and the projecting alveolar process is trimmed to the level of adjoining bone...Bone is smoothened and wound margins are approximated...

After the extraction of several teeth,the margins of the gingival incision are detached and retracted...The bone is smoothened with rongeurs and bone files..Wound is thoroughly iriigated and closed...A conservative crestal alveolectomy and inter-septal alveolectomy is performed simultaneously when the future alveolar ridges are uneven...

In the case of complete arch extraction,complete arch alveolectomy is carried out..An incision is made on the alveolar ridge from third molar to third molar area..The incision is placed slightly on to the buccal side,muco-periosteal flap is reflected lingually or palatally...If the procedure is to be performed in a smaller area,the vertical extension over the incision can be made...All sharp or elongated prominences are smoothened out and undercuts are eliminated..The best method to check the final shape of the ridge is to replace the muco-periosteal flap and gently palpate the ridge with finger over it..Slight trimming of the excess flap is normally required...After irrigation,the wound can be finally closed with interrupted or continuous sutures...

Inflammatory fibrous hyperplasia - Epulis fissuratum

2011-05-17T00:21:00.000-07:00

Inflammatory fibrous hyperplasia is also called as Epulis fissuratum..This is caused by irritation from a faulty or ill-fitting denture or even an allergic reaction to the denture material,,,Continuous flds of mucosa are formed between denture and alveolus leading to lobulated localised mass...Treatment lies in discontinuing the denture for control of acute inflammation...The excessive tissue in the form of single or multiple folds is excised under local anaesthesia with a scalpel or electro-surgical knife..The wound is closed in layers...

Alveolar muco-periosteal hyperplasia

2011-05-17T00:18:00.001-07:00

Hyperplasia on the crest of the alveolar ridge is seen in patients most commonly in the maxillary anterior region in the form of mobile unsupported soft tissue on account of ill-fitting dentures or in patients who have used the same set of denture for many years..It may also lead to the underlined bone resorption...This hypermobile tissue is compressible rendering the denture unstable..The treatment lies in a wedge shaped excision of the soft tissue under local anaesthesia all along the alveolar crest..The wound margins are sutured by interrupted sutures...

High buccal frenal attachments

2011-05-15T23:21:00.000-07:00

High buccal frenal attachments are encountered in maxillary and mandibular premolar areas and if these are grossly interfering with the placement of the denture,a surgical intervention is required..It is either excised as labial frenum or the frenal attachment can be transplanted to the depth of the vestibule...Incision is made near the alveolar crest down to the periosteum...The mucosal margins containing the frenum is reflected and sutured to the periosteum in the depth of the vestibule...The residual defect is allowed to heal by epithelisation..

Labial frenectomy

2011-05-15T23:18:00.000-07:00

A high attachment of the labial frenum can cause instability of the denture and disturb the peripheral seal of the denture...It can be excised under local anaesthesia..Raise the lip...Put a haemostat parallel to alveolar ridge in contact with the mucosa there up to the muco-labial fold...Put another hemostat parallel to the lip at right angle to the first hemostat...Lock this also over the fibres of the frenum touching the tip of te first hemostat..With no 11 B.P.blade,the labial frenum is excised by cutting around the outside surfaces of the two hemostats leaving behind a diamond shaped cut..The lateral margins of the surgical wound are undermined..Close the wound with interrupted sutures starting near the lip and ending on the alveolar ridge at the other end..If a hypertrophied labial frenum is to be excised,a v shaped wedge of muco-periosteum in the area of midline over the interdental bone is excised along with...

Prognostic significance of TNM staging - Prognosis of oral cancer

2011-05-14T00:10:00.000-07:00

Prognostic significance of TNM staging

1.Size of primary tumour and depth of invasion in to adjacent tissues - tumour size greater than 4 cm and deep invasion has poor prognosis...

2.Degree of histologic differentiation - more the tumour shows anaplastic changes the poorer the prognosis..

3.Location of primary tumour site - Poor prognosis seen in posteriorly located lesions..eg..base of tongue..due to general delayed disgnosis and thus a more advanced stage with higher incidence of regional lympph node involvement..

4.Presence of regional node involvement - regional node involvement results in one half reduction of 5 years survival rate for any "T" classification...

Other factors which reduce survival rate are:

a.Growth throught the capsule of nodes with soft tissue involvement..

b.Increasing number of positive nodes

c.Positive nodes spreading to lower levels of neck from submandibular to supraclavicular sites

d.Bilateral and contralateral involvement

Distant metastasis- Most dangerous and generally seen in stage IV..Lung,bone,liver and brain are most common sites for distant metastais of oral cancer

Treatment modalities for oral cancer

2011-05-14T00:09:00.000-07:00

Treatment modalities for oral cancer include:
1.Surgical excision

2.Radiation therapy

3.Chemotherapy

4.Cryosurgery

5.Laser excision

6.Immunotherapy

Choice of treatment depends on:

1.Site and extent of primary tumour

2.The likelihood of complete surgical excision

3.The possibility of preservation of speech and/or swallowing mechanism

4.Presence of bone and / or muscle involvement

5.Presence of metastatic nodal disease

6.Gross tumour characteristic i.e. exophytic superficial vs endophytic invasive

7.Age and physical condition of the patient

8.Social status and occupation of the patient

9.Experience and skill of both surgeon and radiotherapist..

At present cryotherapy and laser excision is used primarily for superficial and accessible tumours...Both chemotherapy and immunotherapy are used as adjuvants for pallation or as adjuvants to surgical and radiation therapy...

TNM classification or Staging

2011-05-14T00:07:00.000-07:00

TNM classification or Staging

The objectives of TNM system are

1.To aid the clinician in the planning of the treatment..

2.To give some indication of prognosis

3.To assist in the evaluation of treatment results

4.To facilitate the exchange of information between treatment centres

5.To contribute to the continuing investigation of human cancer

It is based on the assessment of

T - Extent of the primary tumour

N - Condition of the regional lymph nodes

M - Absence or presence of distant metastases

Primary tumour (T):

Tx - Tumour that cannot be assessed by rules

To - No evidence of primary tumour

Tis - Carcinoma in situ

T1 - Tumour 2 cm or less in diameter

T2 - Tumour greater than 2 cm but less than 4 cm in greatest diameter

T3 - Tumour greater than 4 cm in greatest diameter

T4 - Massive tumour greater than 4 cm in diameter with deep invasion to involve antrum,pterygoid muscles,root of tongue or skin of the neck.

Nodal involvement (N):

Nx - Nodes cannot be assessed

No - Regional lymph nodes not palatable

N1 - Movable,ipsilateral nodes

N1a - Nodes considered not to contain tumour

N1b - Nodes considered to contain tumour growth

N2 - Movable contralateral or bilateral nodes

N2a - Nodes considered not to contain tumour growth

N2b - Nodes considered to contain tumour growth

N3 - Fixed nodes

Distant metastases (M) :

Mo - No evidence of distant metastases

M1 - Distant metastases present

Stage grouping:

Stage I : T1   No   Mo

                    N1a

                    N2a

Stage II:T2   No     Mo

                   N1a

                   N2a

Stage III: T3    No    Mo

                       N1a

                       N2a

          Any T    N1b   Mo

Stage Iv :Any T Any N2b Mo

                              N3

             Any T   Any N      M1

classification of salivary gland tumours

2011-05-13T21:07:00.001-07:00

Classification of salivary gland tumours

A.Epithelial tumours

Adenoma

-Pleomorphic adenoma

-Monomorphic adenoma

-Adenolymphoma

-Oxyphilic adenoma

-Other types of adenomas

Mucoepidermoid tumours

-Acinic cell tumour

-Carcinoma

-Adenoid cystic carcinoma

-Adenocarcinoma

-Epidermoid carcinoma

-Undifferentiated carcinoma

-Carcinoma in pleomorphic adenoma

B.Connective tissue and other primary tumours

-Fibroma

-Fibrosarcoma

-Lipoma

-Haemangioma

-Melanoma

-Lymphoma

structures passing through the parotid gland

2011-05-13T21:06:00.000-07:00

Structures passing through the parotid gland:

Superficial zone occupied by the nerves

a.Facial nerve emerges from the stylomastoid foramen and winds laterally to the base of the styloid process

It gives off five branches:

-Temporal

-Zygomatic

-Buccal

-Mandibular

-Cervical

b.Greater auricular nerve

c.Auriculotemporal nerve

Intermediate zone occupied by the veins

a.Retromandibular vein

b.Anterior division of the retromandibular vein

c.Posterior division of the retromandibular vein

Deep zone occupied by the arteries

a.External carotid artery

b.Transverse facial artery

c.Sometimes the posterior auricular artery

Nerve supply:

Secretomotor supply via the auriculotemporal nerve carrying the parasympathetic fibres from the inferior salivary nucleus via the otic ganglion..

Classification of salivary gland disorders

2011-05-13T21:04:00.001-07:00

Classification of salivary gland disorders:

1.Developmental

2.Inflammatory(Sialadenitis)

-Acute bacterial sialadenitis

-Chronic sialadenitis

-Sialadenitis of viral origin

3.Obstructive and traumatic lesions

-Sialolithiasis

-Retention cysts

-Atropy

4.Functional disorders

-Xerostomia

-Increased salivation or ptyalism

5.Neoplastic lesions

-Benign tumours

-Mixed tumours

-Malignant tumours

6.Autoimmune conditions

-Sjogren's syndrome

Biopsy - Types of biopsies

2011-05-11T01:36:00.000-07:00

Biopsy is the study of tissues removed from living organism to confirm diagnosis through histopathological study...It can be of various types..

1.Incisional biopsy

2.Excisional biopsy

3.Aspiration biopsy

4.Punch biopsy

5.Exfoliative cytology

6.Fine needle aspiration cytology(FNAC)

Excision biopsy is done in very small lesions with less than 2 cm diameter..Normal tissue should be included on the margins..

If the lesion is large,an incision biopsy is performed by removing a wedge shaped segment of the pathological tissue along with surrounding normal zone..

Aspiration biopsy is useful in cases of deep inaccessible sites like in metastasis..This is performed by using a large calibre needle and a glass syringe..At times it is used for cystic lesions to identify the true nature of the contents of the cyst..

Punch biopsy has a very little role in oral surgery and may be used in mass screening of cancer patients...

In exfoliative cytology,the biopsy material is obtained by rubbing the lesion with wet wooden spatula and transferring some of the cells on to the slide for histopathological examination directly..A positive diagnosis is of value while the negative response must be reviewed with caution...

The biopsy shouldnot be performed on pigmented and vascular lesions...The biopsy specimen should be preserved and fixed as soon as it is removed..10% formalin solution is used for this purpose..Care should be taken to handle the specimen so that it is not crushed under tissue holding forceps...

Deep dissection

2011-05-11T01:32:00.000-07:00

Access to the deeper tissues is carried out by different methods..The anatamical planes are duly respected..Consideration must be given to the blood vessels and nerves...Both the surgeon and the assistant must respect the tissues...The deep dissection can be carried out by two ways..

1.Blunt dissection

2.Clevage dissection

1.Blunt dissection:

This is carried out with hemostats,scissors,handle of the knife,gauze sponge and gloved fingers..

2.Clevage dissection:

This is carried out by means of scalpel and sharp scissors..It is normally executed layer wise and is considered superior to blunt dissection as it involves less maceration of tissues...In the oral and maxillofacial procedures a combination of both the techniques is used...

Antiseptics and Disinfectants

2011-05-01T01:00:00.000-07:00

Antiseptics are the chemicals used on living tissues for inhibiting the growth and development of micro organisms...

Disinfectants are the agents that are used on non-vital objects to kill pathogenic organisms but not necessarily the spores of bacteria...Some of the commonly used antiseptics and disinfectants are as follows:

A.Antiseptics:

1.Alcohols:

These are frequently used for antisepsis on skin prior to injection or needle puncture..These are good solvents and hence are good cleansing agents..The solution of choice is 70% (by weight) alcohol..

2.Hexachlorophene:

3% of hexachlorophene gives good results against gram positive organisms...It has been fairly used for many years as surgical scrub and for preparation of the operation site...

3.Iodine and iodine compounds:

These are the most effective antiseptics especially when iodine is complexed with organic surface active agents like polyvinyl pyrrolidone...It shows efficacy against most bacteria,spores,fungi and viruses ..Tincture of iodine 2% is used for application on oral wounds..5% solution of Povidone Iodine is used as microbicidal application on the skin prior to surgery...

4.Aqueous quaternary ammonium compounds:

Benzalkonium chloride is the most commonly used antiseptic...It is well tolerated by the living tissues but it is primarily effective against gram positive bacteria only...

5.Hydrogen per oxide:

An aqueous solution of 3% hydrogen per oxide is an oxidising agent and is particularly effective against anaerobes..It liberates oxygen when it comes in contact with the living tissues...It is used for irrigation of contaminated open wounds after diluting with equal parts of water....

B.Disinfectants:

1.Sodium hypochlorite:

It is an effective germicide..It was used as a disinfectant for the irrigation of wounds before the availability of antibiotics..It is recommended to be used for disinfecting the instruments and linen,etc... especially after the surgery on patients who are HIV positive..

2.Phenols:

Phenolic compounds are probably the oldest group of disinfectants...Their use is recommended for disinfection of walls,floors and furniture,etc...They are highly irritating to the skin and mucosa..Carbolic acid is used in tumour surgery to induce the necrosis of the tumour cells that may remain back accidently in the bony cavity..The application of phenol should always be followed by swabbing with alcohol...

3.Aldehyde compounds:

Aqueous solution of formaldehyde and glutaraldehyde are effective disinfectants..Formalin is not very popular because of its odour and long contact required for disinfection..Glutaraldehyde kills bacteria,spores,fungi and all viruses..Sodium bicarbonate is added to it for activation...It is highly toxic and irritating..So it should not be used on furniture,walls and floors but may be used for metal,rubber and plastics..The instruments must be thoroughly rinsed with sterile water or alcohol prior to use...

4.Chlorhexidine:

20% solution of chlorhexidine gluconate is used for rapid hand disinfection prior to surgery...A solution of 0.2% chlorhexidine gluconate is used as an anti plaque agent(mouth wash)..

5.Cetrimide:

0.5% certimide solution in isopropyl alcohol and purified water is used for washing the skin wounds and skin preparation prior to surgery...It is also used for keeping the cheatle forceps dipped while not in use..

Principles of sterilization - Methods of sterilization

2011-04-29T03:57:00.001-07:00

Principles of sterilization

It is believed that contamination on instruments can serve as a protective covering for micro organisms and prevent penetration of sterilising media..Thus instruments must be cleaned of all debris including blood,saliva and necrotic material prior to sterilization..Soaps and detergents are commonly used along with mechanical clenasing with scrubbers,stiff wire brush or ultra sonic cleansing devices...Soaps and detergents lower down the surface tension of the area on which these are applied allowing the emulsification of the contaminants that are removed in the rinsing process...At times fat solvents like ether and acetone and disinfectants like aldehyde and phenol are also used for cleaning the instruments...The various methods used for sterilization are:

1.Dry heat sterilization:

Hot air ovens are used for sterilization with dry heat that kills by dehydration and oxidation..Usually 160 degrees C for 2 hours or 120 degrees C for 6 hours is widely employed for sterilization of cutting instruments and helps in the maintenance of the sharp edges..Glass bead sterilizers are used for quick sterilization especially root canal instruments..

2.Boiling water sterilization:

Boiling water at normal atmospheric pressure will produce a temperature of 100 degrees C that will kill may bacteria in ten minutes but the spores may not be killed even in twenty four hours...A 2% solution of sodium carbonate is used to elevate the boiling point of water to improve the bactericidal effect...Cutting instruments loose their sharpness by repeated boiling..However glove drains,catheters and rubber tubings can be sterilized if boiled for fifteen minutes..Instruments must remain dipped in water during boiling..

3.Autoclaving:

It is the most effective and practical method of sterilization since it provides moist heat in the form of saturated steam under pressure...

Instruments and materials for sterilization are enclosed in muslin wrappers or paper wrappers...Autoclaving time varies directly with the size of the surgical pack..Usually the packs used for oral surgery requires 30 minutes at 250 degrees F under fifteen pounds of pressure...Less time is required for sterilization of rubber and plastic goods like gloves and cannulas,etc...

4.Oil sterilization:

Hot oil baths are used for sterilizing instruments like handpieces at a temperature of 175 degrees C...Fifteen minutes submersion is required for sterilization...This method should not be used for sterilizing syringes and needles because of the risk of oil embolism...

5.Cold sterilization:

Chemical agents are used for sterilization but not satisfactorily...Heat sensitive instruments are dipped in alcohol or 1:1000 solution of benzalkonium chloride for overnight immersion...Hexachlorophene compounds kill all vegetative bacteria if the instruments are kept submerged for three hours...The effectiveness is doubtful against spores..

6.Gas sterlization:

It provides an alternative method of sterilizing the heat sensitive and water sensitive instruments...Ethylene oxide which is a gas at a temperature of 10.8 Degrees C destroys organisms by alkalisation..The enviornmental conditions of temperature,humidity and pressure are controlled in the sterilizer for a period of six to twelve hours..It takes 1 to 7 days to degas objects like plastics..Formaldehyde tablets are also used for the sterilization of hand pieces,etc.. but it is less popular than ethylene oxide because of its unpleasant odour..

7.Irradiation:

Ionising irradiations like X-rays,gamma rays,accelerated beta rays or nonionizing radiation such as ultra violet light is used to kill the micro organisms..Ionising radiation is used by industry to sterilize disposable material such as needles,suture materials,cannulas,dressins,etc..The advantage is that this sterlization can be carried out with the directions and illustrations etc on the packing without compromising with sterilization..Ultra violet light is most commonly used to purify the air such as in the operation room...

Disposable materials

2011-04-13T05:20:00.000-07:00

Present day oral and maxillofacial procedures are aimed at not only the infection control at the operative site but concept of cross infection has become exceedingly important..Role of Hepatitis B and HIV can ahve frightening consequences if the basic requirements of segregation are not adhered to..In this context,the importance of disposable material is of great value..In day to day practice with the use of disposable injection needles,syringes,suture needles and materials,gloves,etc the incidence of cross infection can be brought down considerably...The disposable materials although not always economical are a big help to maintain the chain of asepsis...Another advantage of disposable articles is the ready availability of presterilized materials for ready use thus saving the time for sterilization...Further,these materials provide protection to the health professional and patients alike as the hazards of handling contaminated material are totally avoided...The blades and needles are for single use thereby sharpness of these is pretty sure..The needles and blades are considered to be potential source of transmission of HIV and HBV as for as cross infection is concerned..Therefore one time use of syringes,blades,suture materials and disposable gloves,etc is of utmost importance..

The items which need disinfection are drapes,bowls,suction tips and waste receivers..Many surgeons have started using even these items in disposable forms..It is expected that the use of disposable materials will shortly become a routine with all maxillofacial surgeons in the very near future..As far as disposal of disposable material is concerned,the proper instructions and precautions must be followed by all surgeons alike...

Draping the patient

2011-04-12T23:04:00.003-07:00

The patient should be carefully draped depending upon the type of anaethesia used and surgery involved..The purpose of draping is to isolate the surgical area from the other parts of the body as well as from non-sterile operating room equipment..The patient's head is covered by double layer of towels..The head is placed on two sterile drapes,one drpae goes around the head whereas other drape lies on the table..This enables a comforatble tilting of the head during the surgery..Additional drapes are used to complete the isolation and surgical site from unscrubbed area..

Preparation of the patient

2011-04-12T02:14:00.000-07:00

It is based on the type of surgery..i.e.if the surgery is an intra oral or extra oral or a combination technique..Patient should have had a thorough oral prophylaxis before hand..Preparation of the surgical site is important to reduce contamination..A circum-oral preparation should precede intraoral preparation..This will prevent the transfer of skin flora to the intra oral site..Intra oral preparation before surgery should be done with iodine or chlorhexidine mouth rinses after removing the mucous,saliva and debris with sterile sponge...This preparation is very important in patients with rheumatic heart disease or with debilitating diseases...
All extra oral procedures should involve the shave of the area of operation on the night of the surgery..Some surgeons prefer to shave the skin just minutes before the surgery..Eye brows are enever shaved these days..Surgeons have also discontinued shaving the scalp these days but the merits of shaving the skin should not be ignored..The area of operation should be prepared with cetrimide solution or hexachlorophene or betadine lotion...The area of operation including a wider surrounding area is scrubbed by beginning in the centre of the area to be preapared and moving away concentrically ...Once the centre has been prepared,it should not be touched again with the same sponge..

Gloving

2011-04-12T02:06:00.000-07:00

Gloving prior to any surgery or clinical procedure:

Presterilized latex or rubber gloves are used..After sprinkling the powder gently on the hands,gloves are rolled on to them using hand to hand and glove to glove technique..If the surgeon is assisted by a scrub nurse,the glove will be extended for the surgeon for slipping the hand in to it..When the surgeon is alone,the left hand must be gloved first..With the right hand the cuff of the left glove is held and the left hand is slipped in to the glove...The right hand glove is then lifted..The fingers of the left glove are inserted on the side of the rolled cuff of the right glove...The right hand is inserted in to the glove and the gloves are pulled in to place..The cuffs are turned over the sleeves of the gown..

Scrubbing

2011-04-12T02:03:00.000-07:00

Scrubbing:

The nails should be neatly clipped and rounded..Nailpolish is permitted for staff nurses but they must not under scrub to preserve it..Wash hands up to elbows with soap and water..Clean nails with nail brush dipped in savlon lotion..Then scrub by means of brush on soap lather from finger tips to the elbows minutely using longitudinal strokes..Do not rinse frequently..Scrub for 10 minutes for the first surgery in the morning..Rinse well by holding hands and arms up so that the water will trickle from the elbows..Remove all traces of soap..Dip the hands in 70% alcohol for one minute..This step has a controversial role and is no longer in practice..Clean and dry the hands in sterile napkins..Dress p for the surgery after scrubbing..Gowns are rolled inside out and upside down so that the working surface is not touched with bare hands..Powder the hands to put on the gloves..

These days conventional soaps are being replaced with newer scrubs containing powerful bactericidal compounds such as 20% chlorhexidine gluconate or povidone iodine..With these a quick and effective surgical hand scrub may be achieved in two minutes..Hand antiseptics containing propanol are claimed to be effective against bacteria including tubercle bacilli,fungi and viruses including hepatitis B and AIDS virus...

Application of bandages

2011-04-07T03:42:00.001-07:00

Different types of bandages may be required in different cases..The commonly used bandages are

Stockinet bandage

Barton's bandage

Towel bandage

Barrel bandage

Four tailed bandage

The bandages are applied as dressings on the wound or for temporary stabilization of the mandible ...Adequate cotton padding should be done under a bandage in order to preserve the health of the underlying skin..