Dentistry Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 11)

Dentistry Review
A Free Booklet Series by Dr. Aryan

Preface:
This is the study material designed by Dr. Aryan with creation and compilation of the best
of the best and the most finest slides on the subject. I would like to offer a billion heartily
thanks for everyone who contributed directly or indirectly to the creation of the material
through creation and dissemination of the scientific information.
Covering everything in one study material is next to impossible. Hence, refer to gold
standard textbooks for building solid concepts or in case of any doubt. Textbooks are
acknowledged at the end of the presentation. If any source has been missed to
acknowledge, it doesn’t lessen their impact and contribution in any way.
Don’t keep searching for pattern between the consecutive slides. You won’t find many.
Rather to boost your recall and review, I have constructed many slides and are deliberately
placed with no much relation between the preceding and the succeeding ones.
The main rule of a review material is that it must make you recall or learn maximum
amount of information in minimum amount of time and space.
Motivational quotes and articles are included within the slides. Always remember that
every good idea, nice piece of information and everything else is literally and absolutely
worthless unless you execute.
If you know everything in the slides in much detail, you probably wouldn’t need this
material.
Best of luck WORK & SUCCESS! Dr. Aryan
(Anish Dhakal)

Local Anesthesia
Dr. Aryan (Anish Dhakal)

Composition of Local Anesthesia

What are the compositions of local anesthetic?
I. Reducing agent: sodium metabisulphite to prevent oxidation of the
vasoconstrictor
II. Preservatives: methylparaben increases the shelf life and acts as a
bacteriostatic agent
III. Fungicide: thymol
IV. Vehicle: modified ringer’s lactate and or distilled water

Le Fort fracture of the Skull
 Classic transfacial fracture of the midface, involving the maxillary
bone and surrounding structures in either a horizontal, pyramidal or
transverse direction
The hallmark of Lefort fractures is traumatic pterygomaxillary
separation
That is fractures between the pterygoid plates (horseshoe shaped
bony protuberances which extend from the inferior margin of
the maxilla) and the maxillary sinuses.

Types of Gingiva

1 - 8
1
Palmer Notation System
2 3
4
5
6
7
8
4
7
8
1
2
3
4
5
6
7
8
Right Left
for Permanent Teeth
8 - 1
8 - 1
1 - 8

A
B
C
D
E
Palmer Notation System
for Primary Teeth
E-A
E-A
A-E
A-E

The International Numbering System
“FDI” Federation Dentaire International
(the two digit system)
The teeth are designated by using two-digits:
a. The first digit of the code is located at the left side of
the number and indicates the quadrant:
In permanent dentition In deciduous dentition
U.R. 1 2 U.L. U.R. 5 6 U.L
L.R. 4 3 L. L. L.R. 8 7 L.L.

Universal system
for
Permanent Teeth
(letters used
A,B,C…. For
deciduous teeth)

Dental Caries definition:
Progressive irreversible damage to the hard part of the
teeth exposed to oral environment characterized by
demineralization of inorganic constituents and
dissolution of organic contents resulting in cavitation.

Causes of Dental Caries:

Confusion Corner: Roots
All incisors, canines, premolars except 1st maxillary
premolars have one root
1st maxillary premolars have two roots (buccal &
palatal)
Mandibular molars have 2 roots (mesial & distal)
Maxillary molars have 3 roots (mesiobuccal,
distobuccal & palatal)

Chronic Gingivitis Chronic Periodontitis
Bleeds on touch Bleeds on touch
Discoloration Discoloration
Loss of stippling Loss of stippling
Swelling Swelling
(@BDSS) Mobile teeth
Apical migration (Gum recession)
True pocket
(@BDSS+MAT)

Tooth extraction is the painless removal
of the tooth, or part of tooth, with
minimal trauma to the investing tissues,
so that the wound heals uneventfully and
no postoperative prosthetic problem is
created.
-Geoffrey L. Howe
(Absolute COI: Hemangioma & AV fistula)

Exodontia indications
Unrestorable caries
Periodontally compromised teeth
Failed endodontic or periodontal treatment
Fractured teeth which cannot be restored
Malposed teeth and over-retained teeth
Therapeutic extractions
Impacted teeth
Supernumerary teeth
Preprosthetic extractions
Teeth in line of fracture
Teeth in line of radiation
Teeth associated with pathologies

Relative Contraindications to Teeth Extraction:
Systemic COI: Local COI:
Coagulopathy History of radiotherapy to jaws
Uncontrolled systemic diseases Teeth within a tumor
Pregnancy (except 2nd trimester) Acute infection or inflammation
Patient on chemotherapy

Steps of Tooth Extraction:
1. Loosening of soft tissue attachment
2. Luxation of tooth with a dental elevator
3. Adaptation of forceps on tooth
4. Luxation of tooth with forceps
5. Removal of tooth from socket

Post-extractioninstructionsinNepalilanguage

Post extraction Instructions in English:
Bite firmly on the gauze for at least 30 minutes. Do not chew the gauze.
Minimum talking for 2 to 3 hours.
Blood may ooze from the extraction site for up to 24 hours which may mix
with saliva an the patient may panic due to the amount of blood. If more
than slight ooze, reapply a fresh gauze and hold in for 30 minutes.
Further bleeding can be controlled by having the patient bite a tea bag
containing tannic acid (as vasoconstrictor).
Do not spit for 12 hours after extraction.
Analgesics as needed. Allow soft diet and avoid very hot foods.
After 24 hours rinse with warm saline water twice a day.

What can you do so that bleeding is minimal?
Avoid smoking or tobacco products for at least 1 week. They would
interfere with your wound healing.
Do not suck on a straw when drinking or spit as this may create
negative pressure at the extraction site and the clot may disintegrate
or dislodge (dry socket formation)
No strenuous exercise for the first 24 hours
After the removal of pressure gauze, you can have cold items like ice-
cream which would act as a vasoconstrictor and minimize bleeding

Complications of Exodontia:
Intra-operative complications Post operative complications
Soft tissue laceration Hemorrhage
Hemorrhage Infection
Luxation of neighboring tooth Numbness
Broken teeth Referred pain
Oroantral communication Pain
TMJ problem Dry socket
Fracture of jaw
Tooth ingestion or aspiration

Hemostatic agents types:
1. Physical agents (bone wax, ostene)
2. Absorbable agents (gelatin foams, oxidized cellulose)
3. Biologic agents (thrombin, platelet gels)
4. Synthetic agents (polyethylene glycol hydrogels, cyanoacrylates)
5. Hemostatic dressings

PRINCIPLES OF SUTURING in Dentistry and Everywhere Else
The needle should be grasped with the help of needle holders at
approximately 3/4th of its distance from the tip of the needle
The needle should never be held at the suture end as it is the weakest
point of the needle and grasping at this point results in either bending or
breakage of the needle
The needle should pierce the tissue perpendicular to its surface.
 The curved needles should be passed through the tissues following the
curvature of the needle to prevent tearing of the tissue
The suture should be placed equidistant from the incision line

When one side of the incision is fixed and the other end is free, the needle should be
passed from the free to the fixed end
 When one side of the tissue is thinner than the other side, then the needle should
pass from the thinner to the thicker side
 when one side is deeper and the other side is superficial, the needle should pass
through the deeper to superficial side
Sometimes extra tissue might be present on one side of the incision and suturing it
would result in ‘dog-ear’ formation
The distance from the incision point to the needle penetration should be less than the
depth to which the needle penetrates into the tissue
 The knot should be not be placed over the wound margins
 Each suture should be placed 3-4 mm apart
PRINCIPLES OF SUTURING in Dentistry & elsewhere

Kruger’s Classification of Mandibular Fractures
Simple or closed fracture
Compound or open fracture
Comminuted fracture
Complicated or complex fracture
Impacted fracture
Greenstick fracture
Pathological fracture

Sublingual Hematoma

Causes of Trismus
Impacted third molar teeth
Removal of wisdom teeth
Removal of tonsil
Radiation therapy to head and neck
Tetanus
Jaw nerve injury
Muscle atrophy
Myositis

Hypothesis for dry socket
Birn’s hypothesis:
Traumatic extraction leads to bradykinin release secondary to pain.
Bradykinin stimulate plasminogen to disintegrate clot.
Nitzan’s hypothesis:
Treponema denticola infection disintegrate blood clot.

Dry Socket: Alveolar osteitis:
It is a focal osteomyelitis in which the blood clot has disintegrated or
been lost, with production of a foul odor and severe pain of throbbing
type, but without suppuration
Due to bacterial proteolytic action or fibrinolytic action of the host

Predisposing factors to dry socket
• Difficult or traumatic extractions
• Extraction Site ( frequent in the
mandible than the maxilla)
• Gender (Female>Male)
• Trauma
• Smoking
• Vasoconstrictors (cause
temporary local ischemia which
increase the risk)
• Microorganisms
• Oral Contraceptives  the
estrogen component of oral
contraceptives enhances the
fibrinolytic activity
• Radiotherapy
• Tobacco users
• Paget’s disease
• Teeth which fracture during
extraction

Management: Dry Socket
The aim of the treatment  keep the extracted socket clean and protect
the exposed bone
Socket irrigated with mild warm antiseptic
Then filled with dressing
 zinc oxide-eugenol paste in an iodoform gauze
Dressing is changed every day
Insertion of either of these agents in the tooth socket at the time of
extraction
 Sulfanilamide and sulfathiazole cones.
 Tetracycline hydrochloride
 Aureomycin

Oral Sub mucosal Fibrosis
An insidious, chronic disease affecting any part of the oral cavity and
sometimes pharynx
Always associated with juxtaepithelial inflammatory reaction
followed by fibroelastic changes of lamina propria, with epithelial
atrophy leading to
Stiffness of oral mucosa and causing trismus and inability to eat.

Management of Oral Submucosal Fibrosis
I. Restriction of habits/ Behavioral therapy
II. Medicinal therapy
III. Surgical therapy.
IV. Oral Physiotherapy

Restriction of habits/behavioral therapy
 Consumption of pan, betel nut, chillies, spices, & commercially available, pan
masalas, guthkas with or without tobacco is increasing. So people should be
encouraged to stop these habits
 Affected patients should be explained about the disease and possible
malignant potential of OSMF.
 Possible irritants should be removed
 Nutritional supplements.

Medical therapy
 Vitamin rich diet
 Antioxidants (lycopene 2000 mcg for 3 months, vitamin E)
 IM injection of iodine-vitamin B complex
 Intralesional injections of hyaluronidase
 Placentrex 2ml solution at interval of 3 days in five divided region
 Topical application of 4% Acetic acid 3 times daily.

Medical therapy
 Injection hydrocortisone with procaine HCl locally in the area of fibrosis fortnightly
 Hydrocortisone 25 mg tablet, in doses of 100 mg/day is useful in relieving burning
sensation without untoward effects.
 Triamcinolone or 90 mg of dexamethasone can be given. This is supplemented with
local injection of hydrocortisone 25 mg at biweekly intervals at affected site.
 Also, vasodilator injections and injection of interferon gamma has been helpful
Surgery includes fibrotomy, cryosurgery and laser treatment.

Dentigerous cyst
Dentigerous cyst is a cyst that originates around the crown of an
unerupted tooth and is thought to be the result of a degeneration of
the dental follicle
Formed due to: fluid accumulation or proliferation of dental follicle
epithelium
Radiologically: well defined unilocular radiolucency surrounding the
crown along with a demarcating sclerotic border

Management of Dentigerous Cyst
Surgical treatment
 larger cyst involves surgical drainage and marsupialization. This procedure results in
relief of pressure and gradual shrinking of the cystic lesion by peripheral opposition
of new bone
Decompression
 small acrylic button or short section of rubber is placed in preformed surgical
opening in cyst which keeps the opening open and permits drainage
Orthodontic treatment
 in cases when you want to retain the tooth, orthodontic movement of teeth should
be carried out

Oro-antral fistula in a Nutshell
Investigations:
 Water holding test
 Butterfly test
 Mouth mirror test
 Opening in apex area of socket
Management:
 If opening is pinpoint, no correction
 Opening up to 5 mm: Pack surgicell and suture
 If opening >5mm: plan surgical closure (buccal sliding flap, palatal rotation
flap, palatal partial thickness flap, buccal fat pad closure)

Nerve Supply to Mandible
Inferior alveolar nerve branch of the mandibular division of Trigeminal
(V) nerve, enters the mandibular foramen and runs forward in the
mandibular canal, supplying sensation to the teeth
At the mental foramen the nerve divides into two terminal branches:
 Incisive nerve: supplies the anterior teeth
 mental nerve: sensation to the lower lip

Classification of Fractures in Dentistry
Open vs Closed
Displaced vs non-displaced
Complete vs greenstick
Linear Vs comminuted
Relationship to the teeth
 Class I: teeth both sides of fracture
 Class II: teeth one side of fracture
 Class III: edentulous
Favourable vs unfavourable

Favorable Fractures
Those fractures where the muscles tend to draw fragments together
Ramus fractures are almost always favorable as the jaw elevators
tend to splint the fractured bones in place

Unfavorable Fractures
Fractures where the muscles tend to draw fragments apart
Most angle fractures are horizontally unfavorable
Most symphyseal/parasymphyseal fractures are vertically
unfavorable

General Management of Fractures:
Antibiotics to prevent infection
 (coamoxyclav + metronidazole)
 Pain relief parenteral NSAIDS:
 (injection diclofenac sodium 50 mg I/M 8 hrly).
Care of orodental hygiene
 by irrigation and chlorhexidine mouthwash

Lichen Planus:
Lichen planus (LP) is a disease characterized by itchy reddish-purple
polygon-shaped skin lesions on the lower back, wrists, and ankles.
 It may also present with a burning sensation in the mouth, and a
lattice-like network of white lines near sites of erosion (Wickham
striae).

Lip and Palate Formation (Embryology)
One from the top of the head down towards the future upper lip;
(Frontonasal Prominence)
Two from the cheeks, which meet the first lobe to form the upper lip;
(Maxillar Prominence)
And just below, two additional lobes grow from each side, which
form the chin and lower lip; (Mandibular Prominence)
The upper lip is formed earlier than the palate, from the first three
lobes.
The back portions are called palatal shelves, which grow towards
each other until they fuse in the middle to form the palate

Management of Mandibular Fractures:
Preliminary management
Examination
 of mouth ,removal of all fragments of teeth, broken filling and dentures
Airway
 if danger of tongue falling back ,then dorsum of tongue should be sutured
Hemorrhage
 facial vessels should be secured with artery forceps, temporary dressing to be
applied

Soft tissue laceration should be sutured within 24 hours of injury
Antibiotics
 Benzyl penicillin to be given IM injection or 1 mega unit every 6 hours
for 1st 2 to 3 days
 Oral penicillin continued for next 1 week
 Oral metronidazole 400-800 mg BD given to all patients with
mandibular fracture

Planned management for Mandibular fractures:
 Reduction  restoration of functional alignment of bone fragments
 Immobilization of fractured bone
• With inter-maxillary fixation and bony plating
• Minimally displaced #  close reduction and intermaxillary wiring
• Severely displaced #  open reduction and intermaxillary fixation

Complications of Mandibular Fracture
Infection
Delayed and non-union
Malocclusion
Inferior alveolar nerve damage
TMJ ankylosis especially intracapsular condyle fracture

1. Condylectomy
2. Gap arthroplasty
3. Interpositional arthroplasty

TMJ Dislocation Management
Explanation and reassurance:
 Most TMJ disorders are benign and will improve with non-invasive
treatment
Rest, patient education and self-care:
 Limit excessive jaw movement by eating soft foods
 Avoid wide yawning, singing, and chewing gum
 Massage affected muscles and apply heat
 Use relaxation techniques; identify and reduce life stresses

TMJ Dislocation (Additional Treatment)
Occlusal splints (bite guards) are removable devices to be worn on teeth
that may help with malocclusion or bruxism
Intra-articular steroid or hyaluronic acid injection might also be helpful
Botulinum toxin A injection may also be beneficial
Surgical modalities include:
Therapeutic arthroscopy
Arthrocentesis
Removal of loose bony fragments
Reshaping the condyle

BassTechniqueofBrushingTeeth

Confusion Corner
Precancerous lesions: A morphologically altered tissue in which
cancer is more likely to occur than its apparently normal counterpart.
Precancerous condition: A generalized state associated with
significant increased risk of cancer.
:WHO (1978)

Maxillary Nerve Division
• PSAN- Maxillary(except mesiobuccal
root of 1
st
molar), corresponding buccal
alveolar bone and soft tissues
• MSAN- mesiobuccal root of 1
st
molar,
premolars, corresponding alveolar bone
and soft tissues
• ASAN- Canines, lateral incisors,
corresponding buccal alveolar bone and
soft tissues

IAN Block
Landmarks: coronoid notch, pterygomandibular raphe, occlusal
surface of posterior mandibular teeth
Parameters:
1. Height of injection: line from coronoid notch to deepest part of
pterygomandibular raphe (parallel to occlusal planes of mandibular
molars)
2. Anteroposterior plane: three fourth of distance between coronoid
notch and deepest part of pterygomandibular raphe
3. Depth of penetration: bone contact

Salivary Gland Tumors

Confirm CSF?

It is a rapidly swelling cellulitis of submandibular, sublingual and
submental spaces, often arising from infection of the tooth roots (2nd &
3rd molars/premolars) that extend below mylohyoid line.
Bull Neck: enlargement and tenderness in submandibular region
Woody tongue: sublingual space involvement- posterior elevation and
protrusion of tongue
Ludwig’s angina

Odontogenic infection: 2nd and 3rd molars most commonly
involved
Trauma
Sialadenitis
Calculi: salivary calculi or IV injection in internal jugular vein –
drug users
Osteomyelitis: in mandibular fracture
Commonly involved organism: Streptococcus
Risk factors for Ludwig’s Angina:

Establishment and maintenance of airway
– tracheostomy; later stages – cricothyroidotomy
– corticosteroids
Antibiotic therapy
– high dose penicillin (IM/IV)
– combination of Gentamycin and Cloxacillin
– penicillin resistance: Clindamycin, Aminoglycosides,
Chloramphenicol
Management: Ludwig’s angina

Incision and drainage
– horizontal incision midway between chin and hyoid
bone under local anesthesia
– release tissue pressure
Supportive therapy
– parenteral hydration
– high protein diet, vitamin supplements
Extraction of offending tooth
Regular follow up with prompt treatment of oral infections
Management: Ludwig’s angina

Ameloblastoma
• A true neoplasm of enamel organ type tissue which
does not undergo differentiation to the point of enamel
formation
Common sites:
 Mandible (80%)- molar angle ramus area
 Maxilla- 3rd molar area, maxillary sinus and floor of nose

Radiographic findings: Ameloblastoma
 Tumor exhibits a compartmented appearance
 Septa of bone extending into radiolucent tumor mass
Fig: Honeycomb appearance Fig: Soap bubble appearance

Treatment of Ameloblastoma
• Principle:
Surgical excision with wide free margins
• Methods:
▫ Curettage
▫ Intraoral block excision: small tumor
▫ Extra oral en block resection: large lesion with ramus involvement
▫ Peripheral osteotomy
 Complete excision with part of bone retained (maintain continuity of jaw)
 Retained part are cortical inferior border of horizontal body, posterior border of ascending
ramus and condyle

Dental Imaging in a Nutshell
Bitewing Radiograph:
 Routine radiograph (visualize crowns of teeth and height of alveolar
bone of posterior teeth in relation to CEJ- junction separating root and
crown)
 Proximal caries, progression of caries, periodontal diseases
 Perpendicular to buccal surface of teeth (bone level more accurate than
periapical views)
 The name bitewing refers to a little tab of paper or plastic situated in
the center of the X-ray film, which when bitten on, allows the film to
hover so that it captures an even amount of maxillary and mandibular
information

Periapical radiographs:
Whole length of tooth (including root) and surrounding bone
Endodontics, apical cyst, after trauma, before extraction for
knowledge of root condition
Progression of endodontic therapy
Detection hypertonia (supernumerary teeth) & impacted teeth

Panoramic radiography/Orthopantomogram
Single image of maxillary and mandibular arches and supporting
structures
Orthodontic treatment, fracture of mandible, lesions like cyst and
tumor, before construction of prosthesis, presence and position of
wisdom teeth, periodontal diseases for overall view of alveolar bone
level
Less radiation dose, easy comparison, helpful in patients with limited
mouth opening
Cost is more, not suitable for children because of length of exposure
cycle, resultant image doesn’t show fine anatomic detail that may be
seen on intra oral radiograph

Techniques in Treatment of a Cyst
Enucleation Marsupialization
 Complete removal of the cystic sac and
healing by primary intention
 Indicated for cysts in which cyst walls
can be removed without damaging
adjacent structures including normal
teeth
Opening of the surgical window at the
appropriate site above the lesion
Continuous surface from the exterior
surface to the interior surface of the cyst
or abscess
Sutured in this fashion, the site remains
open and can drain freely

ANUG Management
Removal of pseudomembrane
 Topical anesthesia
 Areas gently swabbed with a cotton pellet to remove pseudomembrane
and nonattached surface
Rinsing the mouth
 With warm water and 3% H2O2—2 hourly
Antibiotics
– Penicillin or erythromycin with metronidazole for 7 days
Gingival curettage
– After disease process diminished
Supportive treatment
– Copious fluid consumption and nutritional supplementation

Acknowledgements:
Best of the best slides, pictures and information on the web. Special
thanks to all those brilliant minds for their act of creation and
compilation of scientific material without which this work would not
be possible
Oxford Handbook of Clinical Dentistry
Textbook of Oral Medicine, Anil Govindrao Ghom
Essentials of Oral and Maxillofacial Surgery, Wiley Blackwell
Dental Materials at a Glance, J. Anthony

Do grades and marks really matter in life?
https://medium.com/@anishdhakal718/do-academic-marks-and-certificates-
really-matter-in-life-fca228caa0a7

Dentistry Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 11)

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Dentistry Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 11)