Dentistry 2023.pptx

D E P T ; P U B LI C H E A L T H 4 T H Y R
C O U R SE T I T LE ; D E N TI ST R Y
C R E D I T H O U R S ; T H R E E ( 0 1 )
B Y ; D R . N H I A L W A N L O L ( M D)
BARO Gambella College

Module I
Introduction to Dentistry
 Definition of dentistry
 Anatomy and physiology oral cavity
 Pathology of oral cavity
 Dental Caries

Introduction to Dentistry
 Definition;
Dentistry is a study of oral cavity
e.g bones, teeth and soft tissues
 Dentistry is the science and art of preventing,
diagnosing, and treating, diseases, injuries and
malformations of the teeth, jaws and mouth and of
replacing lost or absent teeth and associated
structures.

Anatomy and physiology
 Oral cavity consist of;
 Bones..Upper–Jaw
Lower-Jaw
 Teeth(3parts)
Crown
Neck
Root
 Soft tissues
 Tongue, gum, vocal mucosa, and dentine
 Glands..salivary and lymph node

Parts of the Teeth
6
A tooth has a crown, neck, and root
The crown: the visible part of teeth that projects
from the gingiva
The neck is between the crown and the root
The root is the part fixed in the tooth socket, which
is variant in number

Layers of Teeth
8
Enamel: the outer most layer of teeth in the crown
Cementum: the outer most layer of teeth in the root
Dentin: the middle layer of teeth, forms the main
density of teeth
The pulp cavity: the central part of teeth, contains
connective tissue, blood vessels, and nerve

Sensory innervation and Blood Supply of the jaw
9
 Superior and inferior alveolar arteries/ veins ; branch of maxillary
artery supply tooth
 Upper jaw= superior alveolar nerves
 Lower jaw= inferior alveolar nerves; both make dental plexus
 Inferior alveolar nerve: all mandibular teeth, buccal soft tissues
of premolar, canine and incisors
 Lingual nerve: all lingual soft tissues of all teeth
 Long buccal nerve: buccal soft tissue of all molars
 Anterior superior alveolar nerve: maxillary incisors and
canine, buccal soft tissues of incisors and canines
 Middle superior alveolar nerve: maxillary premolar and
maxillary bone roots first molar, buccal soft tissue of premolar

Cont.…
10
 Post. Sup. alveolar nerve: maxillary molars except
a portion of first molar, buccal soft tissue of molars
 Greater palatine nerve: lingual soft tissues of
molars and premolars
 Nasopalatine nerve: lingual soft tissue of incisors &
canines
 Mandibular premolar region, buccal soft tissue
innervated primarily by mental branch of IAN and
also by terminal branch’s of long buccal nerve

Tongue
12
Muscular organ
Functions in:
Chewing
Swallowing
Speech
 Site of sensory reception:
Taste
Touch
Pain / Temperature

Salivary Glands
13
 Major and Minor Salivary Glands
 Three pairs of major Salivary Glands
 Parotid – below and anterior to the ear
 Submandibular – below the mandible
 Sublingual – anterior floor of the mouth
 Orifices / ducts:
 Stensen’s duct – parotid
 Wharton’s duct – submandibular
 Numerous small ducts of Sublingual
glands
 Over 1000 minor glands
 Buccal, palatal, lingual

The Role of Saliva
14
 Physical protection provides a cleansing effect.
 Chemical protection contains calcium, phosphate, and fluoride. It
keeps calcium there ready to be used during remineralization.
 It includes buffers, bicarbonate, phosphate, and small proteins that
neutralize the acids after we ingest fermentable carbohydrates.
 Antibacterial substances in saliva work against the bacteria; like
lactoferrin, lysozyme, lactoperoxidase, beta-lysin, and
immunoglobulins
 Maintenance of homeostasis on dental surfaces:
 Dissolves and dilutes metabolites
 Maintains proper pH balance
 Reduces plaque

Physiology
Function of oral cavity
 Digestion...mastication/chewing
 Alternate airway....breathing
 Articulation of speech...speaking
 Anatomical support
 Psychology...cosmetic

Pathology
 Pathology of oral cavity is defined as disease
affecting bones, and connective tissues of oral cavity
 Dental caries is a bacterial infection of the teeth
and soft tissues.
 Oral hygiene; caring for teeth, gum and other soft
tissues
 Connective tissue include; gum, and vocal mucosa

Dental Caries
 Bacterial infection of the teeth and connective
tissues.
 Pathophysiology of dental carier
 Food particle + bacteria= form plaque--- plaque
form dental carrier
 Dental plaque is colourless, soft, sticky material
disposed on the enamel.

Transmission of Caries Causing Bacteria
18
 Mutans streptococci are transmitted through saliva, most
frequently the mother’s, to the infant.
 When mothers have high counts of mutans streptococci in their
mouths, the babies also have high counts of the same bacteria
in their mouth.
Dental Plaque
 Dental plaque is a colorless, soft, sticky coating that adheres
to the teeth.
 Plaque remains attached to the tooth despite movements of the
tongue, water rinsing, water spray, or less than thorough
brushing.
 Formation of plaque on a tooth concentrates millions of
microorganisms on that tooth

Dental Caries: A Bacterial Infection
19
 There are two specific groups of bacteria found in the mouth that
are responsible for dental caries:
 Mutans streptococci (Streptococcus mutans)
 Lactobacilli
 They are found in relatively large numbers
in the dental plaque.
 The presence of lactobacilli in the mouth indicates a high sugar
intake.

The following mechanisms contribute to tooth decay
20
 Plaque bacteria that ferment dietary sucrose produce acids that
lower the pH on the tooth surface, promoting demineralization and
eventually, tooth decay.
 Plaque bacteria, such as S. mutans can also utilize sucrose to produce
extracellular polysaccharides, known as glucans, which are adhesive
polymers that enable mutans streptococci to avidly stick to the tooth
surface, thereby causing decay in the underlying structures.

The Caries Process
22
For caries to develop, three factors must occur at the
same time:
A susceptible tooth
Diet rich in fermentable carbohydrates
Specific bacteria (regardless of other factors,
caries cannot occur without bacteria)

The earliest sign of decay is decalcification
24

Root Caries
25
 Root caries is becoming more prevalent and is a concern
for the elderly population who often have gingival
recession exposing the root surfaces.
 Carious lesions form more quickly on root surfaces than
coronal caries because the cementum on the root
surface is softer than enamel and dentin.
 Like coronal caries, root caries has periods of
demineralization and remineralization.

Erosion
27
Cause: Bruxism (Involuntary clenching
teeth; esp. during sleep)
Loss by wear of surface of tooth or
restoration caused by tooth to tooth
contact during mastication or
parafunction
Loss by wear of dental tissue caused by
abrasion by foreign substance (e.g.,
toothbrush, dentifrice)
Progressive loss of hard dental tissue by
chemical processes not involving bacterial
action Cause: GERD
Cause: Over vigorous brushing
Abrasion
Attrition

Diagnosis of Dental Caries and Non Dental Caries
28
Radiographs
Visual
Laser caries detector
Laser Caries Detector
The laser caries detector is used to
diagnose caries and reveal bacterial
activity under the enamel surface.
Carious tooth structure is less dense and
gives off a higher reading than non- carious
tooth structure.

Visual and radiographic appearance of seemingly intact molar

Cross section of molar showing decay

Treatments
31
 Elimination of risk factors
 Scaling, root planning & curettage
 Antibiotic therapy (metronidazole or tetracycline)
 Anti-pain (NSAIDs)
Filling
 Amalgam (a mixture of mercury and other metals (solid/liquid)
used for filling holes in teeth)
 Composite a solid material which is composed of 2/more
substances having d/t physical ch/tcs and in which each substance
retains its identity while contributing desirable properties to the
whole.

Methods of Caries Intervention
32
 Fluoride: A variety of types are available to strengthen the tooth against
solubility to acid.
 Antibacterial therapy: Products such as Chlorhexidine rinses are
effective.
 Salivary flow can be increased by chewing sugarless gum, for example,
those with a non-sugar sweetener such as xylitol.
Preventive measures against
caries
A. Fluoride rinse
B. Chlorhexidine rinse
C. Xylitol gum.
D. Sealants- thin, plastic material
used to cover tooth surfaces. It
protects enamel from attack by
bacterial acids.

Complications of dental carrier
I. Local
 Abscess..pus collection
 Tooth loss
 Pericorinitis
 Chronic tooth pain
 Bacterial infection of the floor of the mouth
 e.g Ludwig’s angina

Dental Carrier cont.............
II. Systemic infection
 Sepsis
 Septic arthritis
 Osteomyelitis
 Septic shock

B Y D R . N H I A L W . ( M D )
FIELDS OF DENTISTRY

Outline
 Prosthodontic
 Endodontic
 Periodontics
 Orthodontic
 Oral and maxillofacial surgery ( OMFS)
 Operative dentistry

Fields of studies
Prosthodontic
Endodontic
Periodontics
Orthodontic
Oral and maxillofacial surgery ( OMFS)
Operative dentistry
37

1. Prosthodontics
The branch of dentistry that deals with the
replacement of missing teeth and related mouth
or jaw structures by bridges, dentures, or other
artificial devices.
38

2. Endodontic
It deals with the tooth pulp & tissues
surrounding the root of tooth.
39
39

3. Operative Dentistry (Restorative dentistry)
Concerned with restoration of parts of the teeth
that are defective as a result of disease, trauma,
or abnormal development to a state of normal
function, health, and aesthetics.
40

4.Periodontic
The specialty of dentistry that studies
supporting structures of teeth, diseases, and
conditions that affect them.
41

5. Oral and maxillofacial surgery
The dental specialty concerned with the
diagnosis and treatment of diseases affecting
the mouth, jaws and orofacial structures.
42
42

6. Orthodontics
The specialty of dentistry that is concerned with
the study and treatment of malocclusions, which
may be a result of tooth irregularity,
disproportionate jaw relationships, or both.
43

A N A T O M Y A N D N O M E N C L A T U R E O F T E E T H
Module II

Outline
 Classification
 Anatomy of tooth
 Parts of the tooth
 Layers of the tooth
 Innervation and blood supply of the teeth
 Nomenclatures system of the teeth

Objective
By the this session, students will be able to;
Classify teeth
Describes normal anatomy of teeth
Explain parts of the tooth
Describes layers of the teeth
List nerves and blood vessels of the teeth
Learn different nomenclature systems of the teeth

Teeth
 The teeth are set in the tooth sockets and used in mastication
and speech
 Two class of teeth:
a) Primary/deciduous
b) Permanent
• Children have 20 deciduous teeth; adults have 32 permanent
teeth
 The 20 deciduous teeth consist of
• 2 incisor, 1 canine, and 2 molar teeth on each side of the
upper and lower jaws
• These teeth are replaced by the incisor, canine, and premolar
teeth of the permanent teeth 47

Parts of the Teeth
A tooth has a crown, neck, and root
The crown: the visible part of teeth that
projects from the gingiva
The neck is between the crown and the root
The root is the part fixed in the tooth socket,
which is variant in number
49

Layers of Teeth
 Enamel: the outer most layer of teeth in the crown
 Cementum: the outer most layer of teeth in the root
 Dentin: the middle layer of teeth, forms the main
density of teeth
 The pulp cavity: the central part of teeth, contains
connective tissue, blood vessels, and nerve
51

Sensory innervation and Blood Supply of the jaw
 Superior and inferior alveolar arteries/ veins ; branch of maxillary
artery supply tooth
 Upper jaw= superior alveolar nerves
 Lower jaw= inferior alveolar nerves; both make dental plexus
– Inferior alveolar nerve: all mandibular teeth, buccal soft
tissues of premolar, canine and incisors
– Lingual nerve: all lingual soft tissues of all teeth
– Long buccal nerve: buccal soft tissue of all molars
– Anterior superior alveolar nerve: maxillary incisors and
canine, buccal soft tissues of incisors and canines
– Middle superior alveolar nerve: maxillary premolar and
maxillary bone roots first molar, buccal soft tissue of premolar
52

Cont.…
• Post. Sup. alveolar nerve: maxillary molars except
a portion of first molar, buccal soft tissue of molars
• Greater palatine nerve: lingual soft tissues of
molars and premolars
• Nasopalatine nerve: lingual soft tissue of incisors &
canines
• Mandibular premolar region, buccal soft tissue
innervated primarily by mental branch of inferior
alveolar nerves and also by terminal branch of
long buccal nerve
53

Nomenclature of tooth
 Nomenclature is the first step in understanding dental
anatomy.
 Tooth numbering or “shorthand” system of tooth
notation is necessary in clinical practice for
recording data and communication.
 The various tooth notation systems are as follows:
A. Palmer notation system
B. Universal notation system
C. FDI system (Federation Dentaire Internationale)
55

A. Palmer notation system
 In 1861 Adolph Zsigmondy of Vienna introduced the
symbolic system for permanent dentition. He then
modified it for the primary dentition in 1874.
 The symbolic system is now commonly referred to as
the Palmer notation system or Zsigmondy system.
Primary teeth
E D C B A │ A B C D E
E D C B A │ A B C D E
Permanent teeth
8 7 6 5 4 3 2 1 │ 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 │ 1 2 3 4 5 6 7 8
56

B. Universal notation system
 In this system for the permanent dentition the maxillary
teeth are numbered through 1 to 16 beginning with
upper right third molar.
 The mandibular teeth are numbered through 17 to 32
beginning with lower left third molar.
 The universal system notation for primary dentition
utilizes upper case alphabets.
 Primary teeth- A B C D E│F G H I J
T S R Q P│O N M L K
 Permanent teeth
1 2 3 4 5 6 7 8│ 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 │ 24 23 22 21 20 19 18 17
57

C. FDI system
The FDI system is a two digit system that has
been adopted by WHO.
In this system the first digit indicates the
quadrant and the second digit indicates the
tooth within the quadrant.
1 to 4 and 5 to 8 as the first digit indicates
permanent and primary dentition respectively.
1 to 8 and 1 to 5 as the second digit indicates
permanent and primary teeth respectively.
58

PERIODONTI
CS
B Y D R . N H I A L W . ( M D )
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Module III

4.Periodontic
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The specialty of dentistry that studies supporting
structures of teeth, diseases, and conditions that affect
them.

PULP AND PERIRADICULAR DISEASES
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The Dental Pulp
 Consists of richly vascularized and highly innervated
connective tissue
 It is surrounded by dentin
 The pulp tissue is in communication with the periodontium
and the rest of the body through the apical foramen and
accessory canals near the apex of the root

PULPITIS
 Is inflammation of the dental pulp resulting from untreated caries,
trauma, or multiple restorations.
 Pulpitis can occur when caries progresses deeply into the dentin
 Trauma disrupts the lymphatic and blood supply to the pulp
 Its principal symptom is pain
Main Cause
1.Infection: spread of dental caries to the pulp
2. Trauma
3. Physical irritation: excessive heat during cavity preparation.
4. Chemical irritation i.e. filling materials or cavity cleansers such as
alcohol, chloroform, hydrogen peroxide
5. Mixed microorganisms which are found in the oral cavity
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 This image shows how the progression of decay, if not treated,
will lead to destruction of the tooth's hard tissue and pulp.
 If treated at the beginning of the decay process (first image), a
small filling would resolve the problem.
 If allowed to continue as in the last image, root canal therapy
would be necessary.
PROGRESSION OF DECAY (CARIES)

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 When Dental decay reaches a depth in the dentin that
is near the pulp tissue inside of the tooth, the pulp tissue can
become inflamed (pulpitis)

Classification of dental pulp disease
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Reversible pulpitis
 Tissue is capable of
returning to normal state
of health if noxious stimuli is
removed
 Sudden mild to moderate
pain or short duration
 Sweat, sour foods or
beverages can cause pain
Irreversible pulpitis
 Higher level of inflammation
 Pulp is damaged beyond the
point of recovery
 Sharp severe pain upon
thermal stimulation
 Pain continues after the
stimulus is removed
 Heat & sweat & sour foods
elicit pain
 Pain may be spontaneous or
continuous

Diagnosis and Treatment of Pulpitis
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Diagnosis is based on clinical findings and is
confirmed by x-ray.
Treatment involves
 Removing decay,
 Restoring the damaged tooth, and
 Sometimes doing root canal therapy (RCT) or extracting the
tooth.

Peri-radical Diseases
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Peri-radicular tissue
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 The tissues surrounding and investing the cervical, middle, and apical
regions of the root are the cementum, periodontal ligament, and
alveolar bone.
Classification of Peri-radicular lesions
Classified into four main groups:
1. Acute apical Periodontitis (AAP)
2. Chronic apical Periodontitis (CAP)
3. Acute apical abscess (AAA)
4. Chronic apical abscess (CAA)

1) Acute apical Periodontitis
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 Etiology
 Extension of pulpal inflammation into the peri-radicular tissues
 Irritants: bacteria toxins from necrotic pulps, chemicals
(irritants or disinfecting agents) over instrumentation &
restorations in hyper occlusion.
 S/symptoms
 moderate to severe spontaneous discomfort as well as pain on
mastication or occlusal contact.
 Application of pressure by fingertip can cause marked pain

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 Diagnosis
 Radiography: "Thickening”
of periodontal ligament (PDL) space
(May be not always)
 Treatments
 Adjustment of occlusion (when
there is evidence of hyper
occlusion)
 Removal of irritants or a
pathologic pulp, or
 Release of peri radicular exudates

2) Chronic apical Periodontitis
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 Etiology: results from pulp necrosis and usually is a sequel to
AAP.
 S/symptoms:
 Asymptomatic or slight discomfort
 Do not respond to electrical or thermal stimuli
 Percussion produces little or no pain there may be slight
sensitivity to palpation, indicating an alteration of the cortical
plate of bone and extension of CAP into the soft tissues

Radiography image: Well-circumscribed lesions and pear-shaped
configuration of periradicular to the canine are typical of CAP.
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3) Acute apical abscess
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 Etiology: microbial and nonbacterial irritants from necrotic
pulp.
 S/symptoms:
 Have moderate to severe discomfort or swelling.
 Systemic manifestations of an infective process such as a
high temperature, malaise and leukocytosis
 Because AAA occurs only with pulp necrosis, electrical or
thermal stimulation produces no response
 However, teeth are painful to percussion and palpation

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 Radiography: range from thickening of the PDL
space (infrequent) to a frank resorptive lesion (usual)
 Treatment: Removal of the underlying cause
(necrotic pulp), release of pressure (drainage here
possible) and root canal treatment
 Clinical significance
 If untreated, a Periapical/apical abscess can develop
into osteomyelitis , septicemia, Ludwigs angina, or
cavernous sinus thrombosis.

4) Chronic apical abscess (Suppurative Apical
periodontitis)
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 Result of a long-standing lesion that has resulted in an
abscess that is draining to a surface
 Etiology
 Pathogenesis similar to that of AAA results from pulp
necrosis and is usually associated with chronic apical
periodontitis that has formed an abscess
 The abscess has "burrowed" through bone & soft tissue to
form a sinus on the oral mucosa or sometimes onto the skin
of the face

Cont…
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 Signs and symptoms
 Because drainage exists, CAA is usually asymptomatic
except when there is occasional closure of the sinus
pathway, which can cause pain
 Clinical, radiographic, and histopathologic features of CAA
are similar to described for CAP.
 An additional features is the sinus tract

A. Apical abscesses occasionally drain
extra-orally (blue arrows)
B. The tooth was retreated nonsurgical
and the chin lesion healed within a few
weeks with some scarring.
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Periapical abscess, Apical periodontitis and Cellulitis.

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Peri-coronitis
 Inflammatory process involving soft tissues covering
crown of partially erupted or un-erupted teeth.
 Develops when food debris & bacteria are present
beneath the gingival flap
 Usually seen associated with impacted mandibular 3rd
molars

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Clinical features
Severe pain
Swollen, red, tender gingiva
Discomfort in swallowing
Restriction of oral opening
Foul taste
Pain may radiate to ear, floor of mouth or
throat
Lymphadenopathy
Malaise & fever

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Treatment
 Antiseptic lavage under the gingival flap to remove gross
food debris & bacteria
 Gingival flap is removed surgically if the tooth to be
retained
 Extraction of tooth if needed
 Antibiotics
 Warm saline mouth rinse

Gingivitis
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 It is an inflammatory lesion confined to the tissue of the
marginal gingiva.
Cause:
 Accumulation of bacterial plaque at or near the gingival
margin.
 The bacterial component of plaque produces and releases
variety of enzymes and toxins (e.g. lipopolysacchardies )
which diffuse through the junctional epithelium and initiate
inflammatory changes in the gingival connective tissues.

Cont…
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Clinical features
• Redness of the gum
• Gum bleeding
• edema of the gum
• Tenderness of the gum
Treatment:
• Oral hygiene
• Plaque control
• Oraldine mouth wash
• Administration of antibiotics

Acute Necrotizing Ulcerative
Gingivitis (ANUG)
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Definition: is an inflammatory destructive gingival
condition which exhibits characteristics clinical signs
and symptoms.
The other names for ANUG are "Vincent's gingivitis" or
"Vincents gingivostomatitis", 'Trench mouth'' and"
Ulcero-membraneous gingivitis“

Cont…
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Causes
Fusiform bacteria
Treponema vincenti
Treponema deticola
Fusobacterium nucleatum
Prevotella intermedia
Porphymonas gingivalis
NB: These bacteria are found in large numbers in the
slough and necrotic tissues at the surface of the ulcer.

Cont…..
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Clinical features
 Inter proximal ulcers covered with a yellowish-white or grayish
debris
 Easily bleed
 Necrosis develops rapidly
 Linear erythema
 Pain
 Halitosis
 Lymphadenitis
 Fever and malaise

Cont….
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Control of the acute phase
Antibacterial cleaning
Irrigation of the wound with 3% hydrogen peroxide
solution
Scaling of the affected teeth
Antibiotics, Metronidazole
2% Chloxeidine mouth wash

Modul IV
EXODONTIA
By Dr.NHIAL (MD)

Module IV Con’t…..
Exodontia
Painless removal of the tooth or root with
minimal injury to the surrounding soft tissue and
bone
Removal of the tooth does not require large
amount of force.
Pain and anxiety control is by:
Local anesthesia results in loss of pain,
temperature and touch but not pressure
91

Cont.…
Duration of anesthesia
 local anesthesia without vasoconstrictors
Maxillary teeth: 10 - 20 minutes
Mandibular teeth: 40 - 60 minutes
Soft tissue: 2 – 3 hours
Lasts longer in mandible due to the density
of the cortical bone of the mandible.
92

Cont.…
Local anesthesia with vasoconstrictor
• Maxillary teeth: 50 – 60 minutes
• Mandibular teeth: 90 - 100 minutes
• Soft tissue: 3 – 4 hours
Long acting anesthesia with vasoconstrictor
• Maxillary teeth: 60 - 90 minutes
• Mandibular teeth: 3 hours
• Soft tissue: 4- 9 hours
93

Indications for removal of teeth
Severe dental caries
Pulpal necrosis
Severe periodontal disease
Mal opposed teeth
Orthodontic reasons
Cracked teeth or fractured root
94

Indications for removal of teeth
Pre prosthetic extraction
Impacted teeth
Supernumerary teeth
Teeth associated with pathologic lesion
Pre radiation therapy
Severe attrition ,abrasion or erosion
Teeth involved in jaw fracture
95

Contraindications for the removal of teeth
 Systemic contraindications
oUn controlled diabetes
oEnd stage renal disease with severe
uremia
oUncontrolled leukemia
oUncontrolled cardiac disease
oUnstable angina pectoris
96

Contraindications for the removal of teeth
o Recent MI
o Severely uncontrolled hypertension
o Pregnancy first and last trimester
o Bleeding disorders like hemophilia
o Platelet disorders
o Pt. on anticoagulants
NB: Absolute contraindication (arterioveinous
fistula and end stage renal disease)
97

Local contraindications
Tooth in the area of tumor
Acute infection
Central hemangioma
98

Instrument used for extraction
1. Forceps
Uses of forceps
To expand bony sockets
To remove tooth
2. Elevator : for loosening
Straight elevator
Periosteal elevator
Cryer elevator
99

Techniques of extraction
1. Closed extraction
Adequate access and visibility needed
Steps for closed extraction
1. Loosening of soft tissue attachment from
tooth
2. Luxation of tooth with dental elevator
3. Adaptation of forceps to tooth
4. Luxation of tooth with forceps
5. Removal of tooth from socket 100

Post extraction care
 Curettage if any peri-apical pathology
 Curette if any debris, calculus, amalgam, tooth & bone
fragment in the socket
 Finger pressure is applied to buccal and lingual cortical
plates to compress the socket
 Moistened 2x2 inch gauze is placed
101

Cont…
2. Open extraction
Indication:
Failure to remove by closed methods
Unfavorable root pattern
Fracture or caries extending to root
Hypercementosis
Impacted tooth
102

Complications of exodontia
 Fracture of crown or roots of the tooth being
extracted
 Fracture of alveolar bone
 Fracture of maxillary tuberosity
 Fracture of adjacent or opposing tooth
 Fracture of mandible
 Dislocation of TMJ
 Displacement of root into soft tissues ,maxillary
antrum
 Bleeding
103

Cont….
Injury to gums, lips, IAN & its branch, lingual
nerve, tongue, floor of mouth, greater palatine
artery
 Osteomyelitis
 Infection
 Trismus
 Hematoma
104

Local anesthesia
 Is the loss of sensation in circumscribed area of body
caused by depression of excitation in nerve endings
or inhibition of conduction process in peripheral
nerves.
 Produces loss of sensation with out loss of
consciousness.
105

Cont…
Advantages of LA:
• It can be easily mastered and can be given by
operator
• Equipment required is limited in amount
• Economical and transportable
• The patency of air way is not impaired
• Enables the patient to cooperate
Contraindications to LA:
 Acute infection in the injection sites
 Patients with hemorrhagic disease
106

Types of LA
1. Topical.
 When applied to intact mucus membrane pass through the
epidermis and anaesthetize the nerve endings e.g.. Cocaine,
lidocaine.
 It can be in the form of sprays, ointment…
2. Infiltration:- Deposition of LA near the terminal fibers to
produce anesthesia to localized areas served by the nerve
fibers.
- Sub mucous injection
- Supra periosteal
- Sub periosteal
* Mostly used in maxilla
107

Cont…
3. Regional anesthesia: Anesthetic solution
deposited near the nerve trunk & blocks all
impulses. It is also known as block
anesthesia.
** It is widely used in the mandible since
infiltration is unreliable due to the density of
the cortical bone of the mandible.
108

Summary of maxillary block
Posterior Superior Alveolar Nerve Block
Maxillary molars (with exception of
mesiobuccal root of maxillary 1st molar
in some cases), hard and soft tissue on
buccal aspect
Middle Superior Alveolar Nerve Block
Mesiobuccal root of maxillary 1st molar ,
premolars and
surrounding hard and soft tissue on buccal
aspect
Anterior Superior Alveolar Nerve
Block/Infraorbital Nerve Block
Maxillary central and lateral incisors and
canine, surrounding hard and soft tissue on
109

Local anesthesia in Mandible
 The regional or block anesthesia in the mandible is achieved
by deposition of LA around the inferior alveolar nerve at
pterygo mandibular space / Retro molar area
For mandibular block:
 Mandibular occlusal plane should be horizontal when
patient open his mouth
 Operator should stand in front of the patient for giving
anesthesia to the right side and behind for the left.
 The thumb of left hand is passed along the buccal surface of
the lower molar teeth until the internal oblique ridge is felt.
Then the tip is rolled in ward to lie in retro-molar fossa.
The mid point of the nail concedes the land mark for
insertion of the needle after preparation
110

Cont…
 The syringe is held parallel to the mandibular
occlusal plane over 2nd premolar of the opposite side.
 Needle is inserted about 0.5cm to anaesthetize the
lingual nerve and advance more 1.5- 2cm to
anaesthetize the inferior alveolar nerve and long
buccal nerve
111

Difficulties and complication of LA
1. Failure to obtain Anesthesia
a) Inadequate amount LA
b) Poor operater technique
c) Missing land marks
d) PH of tissue
e) Expiration of LA
112

Cont…
2. Pain during and after injection
Reduced by - Sharpe needle
- Tensing the tissue
- Slow injection
3. Hematoma formation: Occurs most frequently when posterior
superior alveolar block given.
4. Intra vascular injection: Frequently the patients feels faint.
Has a pale clammy skin, rapid pulse.
5. Trismus:
 Difficulty of opening jaw due to muscle spasm
 Injection to medial pterygoid muscle
6. Infection
113

Cont…
7. Facial paralysis: Injection to the parotid gland
8. Prolonged impairment of sensation due to damage of the
nerves.
9. Broken Needles
-When needle broken, the tissue must be kept under continuous
pressure until the protruding end is grasped by pliers or artery
forceps.
- If the edge is embedded completely, the patient should be
informed and X-ray should be taken to confirm the position and
presence.
114

Cont…
10. Lip trauma:
 Children chews anaesthetized part.
 Adults burn from hot drinks
11. Fainting
In this instance
• Head should be lowered
• Legs elevated
• Tight clothes & belt loosened
• Wet swab applied on brow
• Stimulate respiration
115

Reading assignments
1.Maxillofacial trauma
2.Principles of preventive dentistry or Oral
health
116

117
Module V
Management of Maxillofacial injuries
Introduction
• The facial skeleton is divided into 3 parts
• The upper 1/3: formed by frontal bone
• The middle 1/3: from frontal bone to the level of
upper teeth.
• The lower 1/3: the mandible

118
The causes of maxillofacial trauma
Fights
Falls
RTAs
Occupational hazards- athletic injury,
industrial mishaps
Iatrogenic causes- # of tooth, alveolus,
maxillary tuberosity, #of mandible during
dental treatment.

119
• Radiographic examination
For middle 1/3
- PA view of the skull
- Lateral view of the skull
For the mandibular fracture
- PA view of the mandible
- Right and left lateral view of the
mandible

120
Basic principle life preservation in
traumatic patient
The ABC methods
 Maintenance of patency of Air way
 Bleeding control
 Maintenance of Circulation

121
Factors affecting wound healing
Local
 Infection
 Foreign bodies
 mobility
 poor vascularity
Systemic
Increased age
Disease e.g diabetes
Deficiency e.g malnutrition

122
Basic principles of management of fracture
1) Reduction: the restoration of fracture
fragments to their original position.
• It can be closed or open reduction
 Closed reduction:
• Can be carried out by manipulation or
traction
• No surgical intervention is needed
• Occlusion of the teeth is used as a guide line

123
 By manipulation: by digital or hand
manipulation
- when fragments are adequately mobile
- in patients come soon after trauma
 By traction: fractured fragments are
subjected to gradual elastic traction
Open reduction
- surgical reduction that allows visual
identification of fractured fragments

124
2) Fixation
fractured fragments are fixed to prevent
displacement and for achieving proper
approximation
 Direct skeletal fixation: by plates or
intraosseous wiring
 Indirect skeletal fixation: by arch bar or
intermaxillary fixation

125
3) Immobilization
- The fixation device is retained to stabilize
the reduced fragments until a bony union
takes place.
- For maxillary # 3 to 4 weeks
- For mandibular # 4 to 6 weeks
immobilization.
- In case of condylar # 2 to 3 weeks to
prevent Ankylosis.

126
Fracture of the middle 1/3 of the face
Boundaries of middle 1/3 of the face
Superiorly: line from zygomaticofrontal
suture, across frontonasal suture,
frontomaxillary suture.
 Inferiorly: occlusal plane upper teeth
Posteriorly: sphenoethmoidal junction

127
1) Le fort I
(horizontal fracture of the maxilla or Guerin's
fracture or floating fracture) separation of
dentoalveolar part of the maxilla
- Horizontal # line above the apices of the teeth at
the level of floor of the nose
- Usually bilateral
- Floating of the palate
- Hematoma within the maxillary antrum
- Bilateral hematoma of the cheek
Classification

129
2) Le Fort II Fractures (Low Pyramidal
Subzygomatic fracture )
- line crosses pyramidally from nasal bone
then frontal process of maxilla then lacrimal
bone and infraorbital marigin crosses the
zygomatic buttress then move backwards and
fracture above maxillary tuberosity
- Facial swelling with massive edema
- Subconjuctival ecchymosis and diplopia
- Dish faced deformity

130
- Infraorbital anesthesia both side
- Bilateral hematoma
- Retroposed upper dental arch with anterior open
bite
- Cracked pot sound on percussion of teeth

131
3) Le fort III: (High level #)
 Force is in lateral direction
 Line runs from nasofrontal region then lacrimal bone then
ethemiod bone around the optical canal involving infraorbital
fissure then greater wing of the sphenoid then
zygomaticofrontal suture, and fracture of both side of the
zygomatic arches.
Clinical features:
 Tenderness and separation at fronto zygomatic suture
 Tenderness and deformity of zygomatic arches
 Lengthening of face
- Depression of ocular levels
- Enophtalmos
- CSF leak via nose (csf rhinorrhea)
- Entire middle 1/3 separated from the cranial base.
- Bilateral circumorbital ecchymosis

132
Treatment of middle face fracture:
1. Manual reduction
2. Reduction by traction
3. Open reduction

133
Fracture of the mandible
Largest, strongest and heaviest bone of the face
Classification:
1)Condylar neck 35%
2)Angle 20%
3)Body 20%
4)Parasymphysis 13%
5)Symphysis 11%
6)Coronoid 1%

135
Management
1) Closed reduction
- dental wiring or arch bar is used to get
the occlusion
- for 6 weeks
Indication
- Non displaced #
- Lack of soft tissue over the fracture
- # of children with developing tooth bud
- Coronoid process fracture

136
2) Open reduction
Indications
- Displaced fracture
- Multiple fracture
- Associated mid face fracture
- Associated condylar fracture
Contraindicated if GA is not advisable,
sever comminuted or loss of soft tissue
and severe infection.

137
Condylar fracture
Classified as:
- Non displaced: a crack is seen on
radiograph
- Deviation: simple angulation b/n
condylar neck and ramus
- Displacement: overlap b/n condyle and
ramus
- Dislocation: condylar fragments are
pushed anteriorly and medially

138
Clinical feature:
- Pain and swelling in the region of
TMJ
- Limitation of oral opening
- Deviation towards the involved side
- Blood in external auditory canal
- Lack of condylar movement on
palpation

139
Complication of maxillofacial fracture
Anesthesia
Malunion and deformity
Infection
Derangement of occlusion
Ankylosis of TMJ
Etc….

140
The Temporomandibular Joint (TMJ)
 The Temporomandibular joint (TMJ) is a small
joint located in front of the ear where the skull
and lower jaw meet.
 It permits the lower jaw (mandible) to move and
function.
 Between the condyle and the fossa is a disk made
of cartilage that acts as a cushion to absorb stress
and allows the condyle to move easily when the
mouth opens and closes.

141
TMJ disorders are not uncommon and have a
variety of symptoms.
Patients may complain of :
Earaches
Headaches
Limited ability to open their mouth.
Clicking or cracking sounds in the joint
Feel pain when opening and closing their
mouth.

142
Dislocation of TMJ
Excursion of condylar head beyond the
anterior limit of articular eminence
It can be of:-
- Unilateral or bilateral
- Chronic or acute

143
Causes
Blow on the chin while the mouth is
open
Excessive pressure on mandible while
extraction
Vomiting
Injudicious use of mouth gag during
GA

144
Clinical features
- Deviation of the chin
- Open bite
- Depression in front of the tragus
- Inability to close the mouth
- Drooling of the saliva
- Difficulty in speech and swallowing

145
Management
- Manipulation
- Surgical if chronic

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